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accessible. Military use of the properties of infrared light was a key factor in those advances. 18. The military developed night-vision systems which emitted low-luminosity or invisible radiation. and the method used to direct that stimulus. Pupillary examination involves recording the size.Infrared pupillometry.. Basic concepts and pathophysiology of pupillary response Pupillary size and light reflex have traditionally been used as a validated clinical parameter for detecting cerebral herniation. This method could improve the predictive factor of neurological deterioration and the bedside monitoring of the neurological state of the patient. 13. the examiner's own visual acuity and experience. assessment of 17. Clinical practice guidelines issued by the Brain Trauma Foundation (BTF) recognise that pupil size and reaction to light are early indicators of prognosis for patients with severe HT. and these are usually included in the patient's chart. http://zl. the German scientist Frederick William Herschel discovered what were once called 'calorific rays' while working with glass prisms. These devices may be used in the future as an additional tool for non-invasive neuromonitoring in severely 6 brain-injured patients.es/en/revista/neurologia-295/infrared-pupillometry-basic. 11. However. or when doctors are determining the severity of head trauma (HT). Nevertheless. Since infrared was first described. We also present some recommendations in the SCImago Index routine assessment of pupils in neurocritical patients. analysis of these parameters is affected by significant interobserver variability due to the influence of factors such as differences in ambient lighting.. Nevertheless. assessment of visual function) sleep medicine. testing the effects of drugs on the autonomic nervous system. such as predicting neurological deterioration (neuroworsening) in certain patients. obtain new information about the physiology and pathophysiology of the pupillary response. Such systems were later transformed into cathode ray tubes which allowed images to be viewed on a screen. Pupillary response is also the most important clinical sign of a structural or metabolic coma. including ophthalmological research (pupil diameter measurement in refractive surgery. and light reactivity of both pupils. the intensity of the light stimulus. and cost-efficient method. Pupillary examination with the help of such devices allows professionals to distinguish Horner's syndrome from physiological anisocoria. The word "infrared" comes from the Latin infra (below) and the colour red. these guidelines also include the following statement: "Accurate measurement of pupil diameter or the constrictor response or the duration of the response has not been performed in studies on traumatic brain-injured individuals—for lack of a standardised measuring 3 procedure". This probably explains why testing pupillary reaction to light is generally considered a late-stage marker with a low 5 sensitivity to neurological deterioration. Article Pupil assessment is a fundamental part of the neurological examination process. Wavelengths of infrared radiation are longer than those of visible light (380–780nm). but shorter than those of radio waves. 2 of 9 10/12/2013 7:05 PM . In 1800. Different diagrams or schemas are employed in order to reduce interobserver variability. which is at the edge of the visible light spectrum. 7. and especially since the Second World War. Lowenstein and Loewenfeld published the first study on pupillary imaging with the help of an infrared camera.. 23 autonomic neuropathies. Use of a magnifying ophthalmoscope is recommended in difficult cases as it provides a magnified image of the pupils. assessing the depth of anaesthesia. and observe the result of bedside procedures. routine pupil examination with a conventional light source has undergone no significant changes in the last 100 years. 19 20. pupillary examination is characterised by a response to light which is slower and somewhat less marked than a normal response. especially central transtentorial and uncal herniation.elsevier. which explains why correct pupillary assessment is such a crucial step. and recently. 9. The availability of these devices gives rise to a host of potential uses for them. 14 head injuries or requiring cardiopulmonary resuscitation. Use of this technology for pupillary examination dates back to the 1950s. Exposure to light should last at least 10seconds. They highlighted the possibility of employing their technique for pharmacological and physiological research 16 and as a general screening method. 10. advances in this type of technology have been considerable. 21. In spite of technological advances and substantial progress in our understanding of central nervous system (CNS) pathophysiology. assessment of severely brain-injured patients. and monitoring the effects of different drugs. avoiding unnecessary examinations and enabling early therapeutic intervention. using alternative systems permitting more objective examination of the pupils may be necessary. 12. with both of the patient's eyes remaining open. However. symmetry. Pupillary examination should therefore be carried out with low ambient lighting and a good light source (for example. infrared devices included in digital cameras have led to the development of portable easy-to-use digital systems which enable researchers to carry out non-invasive repeatable studies of pupil size and light reactivity using an objective. In 1958.. The aim of this review is to describe the fundamentals of infrared pupillometry (IP) and discuss its potential uses for monitoring severely brain-injured patients. applications in the monitoring of neurocritical patients. pupillary response is difficult to describe in some cases. Over the last few years. subjective assessments of pupil diameter may lead to errors when used 2 to measure pupils in both healthy patients and in those meeting brain-death criteria or under the effects 4 of anaesthetic agents. Herschel's calorific rays are currently known as 'infrared radiation'. there are numerous clinical applications of IP. For that reason. In the case of severely brain-injured and comatose patients. objective and almost continuous way provides a new non-invasive monitoring method. a halogen lamp). 22. in spite of using methods such as comparison of 1 Rosenbaum card pupillometry. 8. From conventional light stimulus to infrared pupillometry Standard pupillary examination consists of recording the pupil's baseline condition and exposing the pupil 15 to a source of light intense enough to trigger a direct photomotor reflex and a consensus response. Basic principles and their application in the non-i. + info Conclusions The possibility of evaluating the changes in pupil reactivity in an early. Furthermore. pupillary abnormalities help detect expansive processes and are indicators of prognosis in patients with severe 3. At present.
30. Researchers have observed that use of therapeutic doses of desipramine and reboxetine increases latency time and 43 reduces contraction amplitude and pupillary dilation time. resulting from compression of the temporal lobe or adjacent structures. significantly increases pupillary diameter and percentage of constriction (difference between the maximum and minimum diameter). clinical conditions. It is a well-known fact that these drugs affect both the sympathetic and the parasympathetic response. Drugs and specific treatment methods affecting pupillary function In severely brain-injured patients who are sedated and under the influence of multiple drugs. 33. drugs that block muscarinic receptors in the iris. it is important to consider the impact of those drugs on pupillary response. 15. high doses of tricyclic antidepressants. 35. In theory. 26 cases of paradoxical dilation of the contralateral pupil. Muscle relaxants Gray et al. Antidepressants Some researchers show an interest in the effects of tricyclic antidepressants on the kinetics of the pupillary light reflex. Early detection of pupillary abnormalities as a sign of neuroworsening may help reduce the time interval during which compression is present and irreversible brain injury takes place.Infrared pupillometry. Vasoactive drugs High doses of dopamine (α-1 adrenergic agonist) may cause non-reactive mydriasis during general 41 anaesthesia. In the latter case. the pupil partially or completely loses its reactivity to light and subsequently dilates. Hyperthermia Hyperthermia induced in healthy volunteers. However. there are recorded 24. increase response latency and reduce contraction amplitude. Early detection could therefore be 29 associated with better clinical progress and facilitate starting treatment. used IP to show that use of barbiturates modifies pupillary function parameters until they reach ranges considered to be pathological and a burst-suppression pattern 22 appears in the patient's electroencephalogram. causes pupil dilation which is usually ipsilateral to the lesion. any lesion in the midbrain or in the efferent fibres forming cranial nerve III.5°C) with or without general anaesthesia with isoflurane. However. for many substances commonly administered to these patients. whereas use of anaesthetics compromises 32 pupillary response in a dose-dependent manner by up to 80%. which is a false localising sign. In a recent study. It has been observed that patients with phaeochromocytoma present anomalous pupillary responses similar to those in brain death. Hypoperfusion of brainstem structures may also evoke 27 these kinds of changes. This stereotypical progressive pattern of changes in pupil size and light reactivity seems to indicate that early detection of such anomalies is very important in order to assess clinical progress in severely brain- 10. and profound hypothermia (<28°) are the most frequent causes of altered pupillary response and increased pupil size. pathological ranges were either not reached or the effects caused by these drugs were short-lived. such as atropine. In our experience. we can affirm that barbiturates. Alterations of the photomotor reflex and causes of pathological pupil dilation Cranial nerve III is closely linked to the medial part of the temporal lobe (uncus of the hippocampus) and to areas of the brainstem which control consciousness. However. However. Although use of propofol and midazolam significantly reduced pupillary response. 40 described cases in which pupillary reflexes were absent and the patient appeared to be brain dead. whereas drugs that decrease the impulses of the sympathetic nervous system (such as 25. it would be the first sign of compression of vital structures. Therefore. Larson et al. 11. 31 clonidine) reduce the dilation velocity of the pupillary sphincter. and treatment methods which are most commonly associated with severely brain-injured patients and may modify pupillary size and response. deep hypothermia (<28°C) 6. assessed the effect of vecuronium and pancuronium on pupillary response at a dose evoking complete block of muscle response to peripheral stimulation. 34.es/en/revista/neurologia-295/infrared-pupillometry-basic.. The most common effect of tricyclic antidepressants is enhancement of the sympathetic response by blocking noradrenaline reuptake in the synapse (α-2 receptors) and inhibition of 43 the parasympathetic response through a postsynaptic muscarinic blockade. 28 injured patients. and nitric oxide). When compression of cranial nerve III is significant. For example. enflurane. Their pupillometry study showed no 32 changes in patients' pupillary response. Nevertheless. whether or not it was associated with inhalation anaesthetics (isoflurane. showed that high doses of barbiturates for the treatment of status epilepticus 38 completely abolish brainstem reflexes except for the photomotor reflex. it is difficult to determine which arm of the autonomic nervous system is affected the most.. This review lists the drugs. Hypothermia Using an infrared pupillometer. patients with intracranial hypertension treated with barbiturates frequently experience an increase in pupil size and a decreased pupillary response to light stimulation. This partially reverts the inhibition of the photomotor reflex induced by anaesthetics. This is probably due to adrenergic hyperstimulation of the 42 iris. Barbiturates and benzodiazepines Lowenstein et al. 36 may abolish pupillary and brainstem reflexes. Taylor et al. we should not forget that loss of pupillary response to light is not always related to compression of cranial nerve III. They observed that moderate hypothermia does not modify pupillary reflex.2±0. http://zl. To summarise. 3 of 9 10/12/2013 7:05 PM . others have 39. The 3 inhalation anaesthetics used by these researchers significantly decreased both parameters but did not abolish the photomotor reflex at doses 37 commonly used in clinical practice. lower reactivity to light may indicate compromised function of cranial nerve II or III.. Basic principles and their application in the non-i. 25. assessed pupillary response in patients in a state of moderate hypothermia (32.elsevier..
47. In such patients it is important to perform a standardised evaluation of pupil size and response to light so as to assess the patient properly and compare results with those in the literature. Such devices include: (a) an integrated intense light source for pupil stimulation. The NeurOptics™ ForSite pupillometer (NeurOptics Inc. and (d) an image capture system with an infrared digital camera which can obtain data in different lighting conditions. the authors detected 49 that most of the children presented a baseline pupillary asymmetry which did not exceed 0.). 46. Pupil dilation velocity. (c) a light source emitting a standardised stimulus. or severe disability). Additionally. Pupillary latency time. (b) an image capture system with an infrared digital camera capable of obtaining pupil measurements throughout the entire examination process (pupil diameter at rest. 5.. 7. Pupillary examination using a NeurOptics™ ForSite pupillometer All pupillometry devices developed to date function according to the same basic principles. Amplitude of pupillary constriction refers to the difference between maximum pupil diameter before light stimulation and minimum pupil diameter after light stimulation. The laterality of an abnormal pupil should be reported. 4.. doctors should correct any hypotension or hypoxia and rule out the possibility of direct ocular trauma. NeurOptics. It also includes a removable headrest which allows us to position the pupillometer correctly before the 4 of 9 10/12/2013 7:05 PM . vegetative state. Figure 1. Our market contains various brands of pupillometers (Colvard. without interfering with pupil response because it provides no visible light.es/en/revista/neurologia-295/infrared-pupillometry-basic. Irvine. We should stress that definitions of non-reactive pupil and pathologic anisocoria are based on direct observation of the pupil and its photomotor reflex. Percentage of decrease in pupil diameter is defined as the difference in pupil diameter after light stimulation expressed as a percentage. Therefore.. during light stimulation. 41. 48 even to the point that alterations may resemble indicators of brain death. http://zl. CA) used in this study. Pupil constriction velocity refers to the decrease in pupil diameter in millimetres as a function of the elapsed time required for the pupil to reach its minimum diameter from its maximum diameter. (b) a keyboard to introduce data such as patient ID data. Definitions and methodological recommendations for assessing photomotor reflex Assessment of pupil size and photomotor reflex is part of routine care for all neurological patients including those with severe brain injuries. since its absence in both eyes has a positive predictive value of more than 70% (class I) for a poor neurological result (death. from total darkness to bright light.. 45. most of which are used in the field of ophthalmology. and c) a data processor to perform calculations. Use of automated devices would also permit the inclusion of other pupillary examination parameters that cannot be measured using direct observation and which are listed below.elsevier. 6. refers to the recovery of baseline pupil diameter over time. and intracranial pressure (ICP) values. 44. whereas dilation velocity is conditioned by the sympathetic nervous system. is defined as the time between exposing the pupil to a light stimulus and the onset of iris constriction. 3. The NeurOptics pupillometer is the only portable pupillometer specifically designed to assess pupils in severely brain-injured patients (among others). use of the automated pupillary assessment procedures mentioned above could modify these definitions. It is important to recall that latency time and amplitude of pupillary constriction are conditioned by the parasympathetic nervous system activity. Pupils should be reassessed after surgical evacuation of intracranial haematomas. constriction and dilation velocities also depend on the initial pupil 49 diameter. Basic principles and their application in the non-i. The pupillometer includes: (a) a built-in microprocessor with a colour LCD screen displaying measurements in both graphical and numerical formats. Procyon. Pathologic anisocoria is defined as pupillary inequality >1mm.. and at the end of the stimulus). medications. Pupillary assessment should always be carried out after cardiopulmonary resuscitation. NeurOptics™ ForSite pupillometer (NeurOptics Inc. 2. also expressed in millimetres per second. expressed in milliseconds. The BTF's definitions and 3 recommendations for pupillary examination are as follows : 1.. Irvine.5mm. CA) is a portable device powered by rechargeable battery (Figure 1). Prior to pupil assessment. A fixed or non-reactive pupil is defined as one that does not present a constrictor response to bright light. 8. Photomotor reflex should be used as a prognostic indicator. In a recent study aiming to establish normal ranges for pupil response in paediatric patients using an automated pupillometer. etc.Infrared pupillometry. A mydriatic pupil is defined as one having a diameter exceeding 4mm. The clinical practice guidelines recently published by the BTF for the treatment of patients with HT currently provide the clearest normative data.
Infrared pupillometry. Limitations of the NeurOptics™ ForSite pupillometer The NeurOptics device is monocular. Such studies have yielded relevant data for the evaluation of refractive surgery. their results are both interesting and encouraging. They presented some preliminary observations concerning pupillary responses with different lighting conditions. 22 severely brain-injured patients. Nevertheless. (b) When the device has detected the image correctly. According to their study. (c) there is an analysis phase lasting from 8 to 10seconds during which all pupillary images (39 images per second) are analysed sequentially and the screen displays the results in both graphical and numeric formats (Figure 2).6mm/s on 53% of the measurements when ICP values were higher than 20mmHg. a pupil constriction velocity of less than 0. meaning that it cannot measure consensual response.es/en/revista/neurologia-295/infrared-pupillometry-basic. Throughout this phase. this device cannot be used for assessing patients who have suffered an eye trauma or who have a history of iris surgery or dysmorphia. on the other hand.. which lasts 3seconds. Use of pupillometer in a severely brain-injured patient. pupillometry could be a low-cost screening method for continuous evaluation of 21 patients with HT and in early detection of brain herniations. which allows us to save graphic displays so that they can be analysed 20 subsequently. pupillary response is preserved with use of opioids and. In order to obtain valid data. pupillary areflexia may be intermittent with an uncal herniation.6mm/s was detected in only 0. and constriction velocity/dilation velocity in millimetres per second. However. 21. pupil constriction velocity remained the same until ICP values exceeded 24mmHg.35% of measurements taken from healthy volunteers. Moreover. All stored data can be sent to a thermal printer by means of an infrared communications port. Figure 3.elsevier. A photomotor reflex examination carried out with this system consists of 3 automated phases. a fixed-intensity. patients with HT and midline shifts of more than 3mm according to the brain CT showed values below 0. Figure 2. An afferent pupillary defect. we think that the study by Taylor et al. diameter of the minimum pupillary aperture in millimetres (after stimulation). Graphic and numerical data displayed on the pupillometer screen after light stimulation. Pupil constriction velocity: according to these authors. this phase starts after we place the pupillometer in front of the patient's eye and press the scan button. sleep studies. (a) The first is a search for the objective. concomitant use of drugs which could modify pupillary response. constitutes the most important contribution to date. Only a few preliminary studies have been completed which use this non-invasive monitoring tool to assess 20. These authors took pupillometric measurements in both healthy volunteers and patients with HT and spontaneous subarachnoid haemorrhage. The device measures the following variables: diameter of the maximum pupillary aperture in millimetres (baseline or before stimulation). These authors concluded that. could therefore go undetected by this pupillometer. which may be present with optic nerve lesions in patients with HT. patient's eye during the measurement process. The only point of contact between the device and the patient is a disposable support that creates the distance needed in order to hold the device correctly during the examination (Figure 3). On the one hand. They concluded that IP could reveal the presence of a midbrain impairment that would otherwise have been overlooked in pharmacologically paralysed patients. which allows the operator to centre the iris properly. In patients with diffuse cerebral swelling and no midline shift. the pupillometer must rest correctly over the orbital area so that it does not move during the examination. Moreover.8seconds). the screen shows a video image of the eye. values below 0. Basic principles and their application in the non-i. IP has also been used to objectively measure emotional response in patients with psychiatric disorders and to ascertain autonomic response in patients with diabetic neuropathy. and ICP values. These values are uncommon in healthy subjects. a new phase begins in which images are acquired during 3seconds. percentage of variation between the above measurements. Use of pupillometry in severely brain-injured patients Clinical uses of IP have mostly been studied by the field of ophthalmology.. During this first phase. This explains some of the interobserver differences that have been recorded. compared to brain CT. since 20 motor responses for the remaining brainstem reflexes are abolished under these circumstances. latency in milliseconds.. However. described pupillometric analysis in a series of patients whose pupillary reflex was absent according to direct observation. they compared a pupillary assessment performed by nurses in a patient subgroup with an evaluation using a pupillometer.8mm/s is associated with an increase in ICP. Larson et al. These 3 phases are described for the patient we present as a model in our article. In 1995. fixed-duration light stimulus is automatically emitted (0.32% of the volunteers. The infrared digital camera simultaneously records pupillary images. The same group subsequently assessed pupillary response in 3 patients with uncal herniation detected by 21 cerebral CT and highlighted 2 key points.8mm/s were found in only 1. Last of all. 5 of 9 10/12/2013 7:05 PM .. and assessing the effects of different drugs on the CNS. Some of the results are 22 summarised below. Constriction velocity of less than 0. http://zl. 1.
Adults Children (1–2 Children Children Children Parameter (mean+SD) years) (2. 2. This parameter therefore has little predictive value for detecting neurological deterioration.1–18 years) Maximum pupillary 4.62 2. have a marked effect on pupillary response. Left pupil size was 4mm and right pupil size was 2.40 36.11 4. altered pupillary responses appear when ICP values exceed 30mmHg. Normal pupillary values. Upon admission.83 4.57 (%) Constriction velocity 1.65 (mm/s) Latency (s) 0. Pupillary symmetry: healthy volunteers and patients without intracranial pathology usually present pupillary asymmetry of less than 0.Infrared pupillometry.65 2. A percentage of decrease in pupil diameter of <10% after stimulation may be considered a definite indicator of brainstem or cranial nerve III compression.. the patient's brain CT showed a right temporal contusion with a volume of 15 cc and no midline shift (Figure 4). pupillary parameters obtained when drugs commonly used in ICUs are administered confirm that use of high doses of barbiturates. they were only reported in 0. and that the slightest change in pupillary response should alert doctors to the possibility of a deteriorating condition.65 2. which leads us to believe that this level of asymmetry may be considered within normal limits. SD: standard deviation. of 310 healthy adult volunteers examined with infrared 22 pupillometry. in which the mean percentage of decrease exceeded 15%.68 33. anisocoria was detected on the second day after admission by direct examination of the pupil.65 2. Continuous ICP monitoring showed initial values within the normal range (below 15mmHg). Combined use of morphine and midazolam has only a brief effect on pupillary response. Figure 4. both were reactive to light. such asymmetries were only detected in 22% of the 22 cases. 5. allows us to draw several conclusions. in a series of children 49 with no neurological or ophthalmological diseases.77 2.4 0. The possibility of carrying out a quasi- continuous study of pupillary dynamics and their relationship with processes that lead to brain herniations 8 could help us predict neurological deterioration. In the presence of bilateral diffuse cerebral swelling.227 0.1–6 years) (6.220 Data obtained in the study by Taylor et al. Nevertheless. decreases in pupil diameter of less than 10% were more common.. Pathological values for constriction velocities (below 0. Table 1 shows 'normal' values obtained by using IP on 310 healthy volunteers in the study by Taylor et 22 al. However. which can result in a flatline or burst-suppression pattern on the EEG.222 0. Illustrative case study A patient aged 16 years with no history of relevant disease was admitted to the Neurotrauma ICU in our hospital after suffering severe HT (Glasgow Coma Scale score of 8) due to a motorcycle accident. The study by Taylor et al. Latency of pupillary response: latency is directly related to age.34 34. With ICP values still within the normal range. This table also includes values from the study by Boev et al.es/en/revista/neurologia-295/infrared-pupillometry-basic.21 2.1–12 years) (12.24±0.04% of all measurements.. This coincides with prior observations indicating that patients with brainstem and/or cranial nerve III compression 27 present higher ICP values than patients with midline shift. This table also includes values obtained in the study by Boev et al.48±0.5mm 22 in 81% of the measurements when ICP values exceeded 30mmHg. of a series of 90 children with no 49 neurological or ophthalmological pathologies. patients having an intracranial pathology with focal lesions and mass effect showed pupillary asymmetries of more than 0.7±0. Pupillometry and drugs: according to the study by Taylor et al..65 2. The larger of the 2 pupils was thought to be pathological and the brain CT was repeated. which remained stable during the first 24hours after admission. In the series described by Taylor et al. in groups of patients with ICP values higher than 20mmHg. 4. 3.07 3. The same is true of patients with HT and ICP values below 20mmHg. even when ICP values are normal.6mm/s) and the percentage of decrease in pupil diameter after light stimulation (below 10%) are recorded even when ICP values remain normal.. 6 of 9 10/12/2013 7:05 PM . Initial brain CT of a patient with severe head trauma showing a small right temporal contusion. and it rarely exceeds 360ms when ICP values are higher than 30mmHg.34 3.83 aperture at rest (mm) Minimum pupillary 2.231 0. http://zl. Basic principles and their application in the non-i.elsevier.1±0.5mm. In the parallel study carried out by nurses using conventional methods.6mm. Table 1.54 aperture at rest (mm) Decrease in diameter 34 33.33 2. Note that brain CT shows no midline shift. Percentage of decrease in pupil diameter: decreases in pupil diameter of less than 10% are extremely rare in healthy subjects. The most important point may be that pupillary response is consistently symmetrical in healthy subjects..
These possible uses will depend on the publication of new studies to corroborate and expand on findings that have been observed up until now. (d) it enables establishment of normal values to allow detection of pathological states. Since findings from the routine brain CT were indicative of an incipient uncal herniation. (c) it enables measurement of parameters that cannot be assessed clinically such as constriction/dilation velocity and percentage.69 Latency 0. given that: (a) it standardises intensity of the light stimulus. http://zl. this was initially identified as a Kernohan's notch phenomenon.. and no midline shift was observed.86 Dilation velocity (mm/s) 0. Conclusions The possibility of performing an early. and process data in computerised systems for future comparisons.2 3. right temporal contusion appeared more defined. and (e) it lets us record.5 2. Figure 6.J.. (b) it permits measurement of the response to the light stimulus. This method would eliminate unnecessary tests and facilitate early treatment. doctors performed a decompressive craniectomy with partial resection of the area of temporal contusion (Figure 6).3 (mm) Minimum pupillary aperture at rest 2. 7 of 9 10/12/2013 7:05 PM .4 (mm) Decrease in diameter (%) 12 13 22 19 Constriction velocity (mm/s) 0.69 1.Infrared pupillometry. Immediately after surgery (decompressive craniectomy and resection of the anterior temporal pole) pupillary function measurements were found to be within normal ranges. Nevertheless.. Table 2. RE: right eye.200 0. J. According to this new scan. and nearly continuous assessment of the changes in pupillary reactivity constitutes a new non-invasive monitoring method that could identify predictive factors for neurological impairment and be helpful in bedside monitoring of a patient's neurological state. However.6 4 3. Patient with HT (preoperative Patient with HD (postoperative Parameter values) values) RE LE RE LE Maximum pupillary aperture at rest 2. which eliminates measurement errors.230 Brain CT showed a right temporal contusion with mild mass effect and no clear evidence of brainstem compression. Pupillary reflexes measured by the pupillometer (Table 2) showed obviously abnormal values for right pupil constriction velocity. IP has significant advantages compared with direct observation of the pupillary response. Sahuquillo by FIS (Fondo de Investigación Sanitaria).66 0.. which until then had been considered normal (Figure 5). Pupillometric measurements after surgery showed that constriction velocity values for the right pupil had returned to normal and coincided with those for the left pupil. pupillometric data was indicative of compromised function of the pupil ipsilateral to the lesion rather than impairment of the larger pupil. there were no new lesions. Figure 5. Postoperative brain CT in which both ambient cisterns are visible with no signs of compression. The patient subsequently recovered well with no additional pupillary alterations (Table 2). there were signs of effacement of the perimesencephalic cisterns ipsilateral to the right temporal lesion.20 0.230 0. Data obtained using pupillometry in a patient with severe head trauma (HT). Acknowledgements This review was partly funded by grant PI080480 awarded to Dr.elsevier. save. LE: left eye. Basic principles and their application in the non-i.5 4. the importance of which is currently unknown. objective.es/en/revista/neurologia-295/infrared-pupillometry-basic. We would like to thank the nursing staff at the Neurotrauma ICU and T. Direct pupillary assessment showed a mydriatic but reactive pupil contralateral to the lesion.40 0. and response latency. Conflicts of interest The authors have no conflicts of interest to declare.84 1. corresponding to the smaller pupil.230 0.7 3. Preoperative cerebral CT showing an increase in the area of the contusion and partial compression of the right ambient cistern. The values were in ranges considered 22 pathological according to the study by Taylor et al.5 1.
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Infrared pupillometry during uncal herniation. 2003.Infrared pupillometry. Medline 3. 13. Ann Neurol. Blunt BA.Litvan L.Meeker M. 1995. Gennarelli TA.Fischbeck K. 12. 2001.Wilhelm H. Neurology. Posner JB. Autonomic components of the human pupillary light reflex.55:437-43. Luedtke H. Neurocrit Care. Ceurrmans P. a new technology: normative data and preliminary observations in patient with acute head injury. Medline 29. Sica REP. 1997.59:352-63. 2000.Marshall L.net Bibliography 1. Neurosurgery. Barnes T. The authors would like to thank Medtronic for donating the NeurOptics™ pupillometer to our hospital so that we could complete the study. Neurosurgery. The outcome of severe closed head injury.Lowenstein O. et al. 5. 15. Machinis T. Larson MD. Use of admission Glasgow coma score. 1958. 1980. Muhiudeen I. 1999. Teasdale G. 1980. J Neuroophthalmol. Medline 33.4:526-54. Hayes J. González L. Clinical implications of quantitative infrarred pupillometry in neurosurgical patients. Bernard. 1983.52:369-72. Medline 28. 2004.Sakas D. et-al.344:1215-21. 2000. Agreement and repeatability of infrared pupillometry and the comparison method. et-al. Fountoulakis KN.Zhao D. Benedict B. Ward J. Br J Ophthalmol. et-al.. Brian S. Brain stem blood flow. 1991. Jewett Don L. 31. Neurosurgery. Gautille T. ☆ Please cite this article as: Martínez-Ricarte F. Wasser TE. Neurological deterioration as a potential alternative endpoint in human clinical trials of experimental pharmacological agents for treatment of severe traumatic brain injuries.Heller Philip H. sahuquillo@neurotrauma.44:941-8. 2003. Robinson J. Clin Physiol. Bachetti P. Medline 4. 1999.Larson MD. De Jesus V. Medline 2. pupil size.29:825-8. Kapsalaki E. Garcia R. pupillary response. Marshall S.34:840-6. 16. Pupil examination: validity and clinical utility of an automated pupillometer. http://zl. 2005. Physiology of the eye. Bailey M.Wachler B. 2001. J Trauma. Crit Care Med. Arch Neurol. 8 of 9 10/12/2013 7:05 PM . 1980. The opposite pupil in herniation. 2013. Holland MD. Electronic pupillography: new instrument and some clinical applications. Wilhelm H. 2002. and Iván Adrián Martínez Ricarte for their assistance with our study.54:530-1.75:S28-36. 1961. Medline 22. Effect of age on the pupillomotor field. The oval pupil: clinical significance and relationship to intracranial hypertension.106:319-23. 7.58:566-8. Neurosurgery. Barba D. The American Association of Neurological Surgeons . 11. Wann SR. Palikaras A. Gautillet T. Saposnik G. Part 2: early indicators of prognosis in severe traumatic brain injury: pupillary diameter and light reflex. 1995. J Neurosurg Anesthesiol. Autonomic nervous system and the eye.Patel AD. Goulas A. Chen J.Gray A. Descripción y fundamentos de la técnica y su aplicación en la monitorización no invasiva del paciente neurocrítico. J Cataract Refract Surg. Oval pupils. Pupillometric analysis of the "Absent Light Reflex" Arch Neurol. Simon R.. The localizing value of asymmetry in pupillary size in sever head injury: relation to lesion type and location.20:336-47. Medline 32. Medline 24. 14. Arch Neurol. J Neurosurg.elsevier. False localizing signs.. Boev A. Muizelaar JP. Estimation of pupil size by digital photography. 1998. Ophthalmology. 1990. Maurino J. Automated standardized pupillometry with optical method for purposes of clinical practice and research.24:228-34. Alexopoulos L. Fatouros P. Received 16 March 2010 Accepted 13 July 2010 Corresponding author. Medline 30. Bullimore M.98:205-13. Marina Maciá. Choi S. 17. Invest Ophthalmol Sci.Wijdicks E. 20. Klauber MR. 1938.Jefferson G.Marshall LF. Medline 25. Pasquale MD. The diagnosis of brain death.Morris G.
1988. Elsevier España S.355:375-6.87:849-55. 2000.Larson MD.Belani KG. 1991. Szabadi E. Medline 34. Tayefeh F. Herman W. Medline 38.es/en/revista/neurologia-295/infrared-pupillometry-basic. et-al. Simon RP. Sussmane JB. Sessler DI. Washington DE.Theofilopoulos N. The Lancet. Isoflurane. Medline 37. McGuire J. Lopez MA. Hynson JM. 1989. 35. Aminoff MJ. 1993.75:62-7. 9 of 9 10/12/2013 7:05 PM . 1974. Alfentanil blocks reflex pupillary dilation in response to noxious stimulation but does not diminish the light reflex. Effect of dexmedetomidine. Suppression of brainstem reflexes in barbiturate coma. Crit Care Med. Pupil size and light reactivity in hypothermic infants and adults.Infrared pupillometry. 6):496-500. Bradshaw M. Bilateral dilated nonreactive pupils during surgery in a patient with undiagnosed pheochromocytoma. Barbiturate anesthesia in the treatment of status epilepticus: clinical experience with 14 patients.Boev MS.103(Suppl.Lowenstein DH. Feltes C.9:658-9.Tyson R. The pupillary light reflex: effects of anesthetics and hyperthermia. 1995. Chyatte D. 2001.Gilbert M. Medline 41. Editors & Reviewers CME Books About About Elsevier Other websites Elsevier Resources Even more Corporate Information Elsevier Ciencia y Elsevier Farma Buy Books Contact Economía Instituciones Medicine Help Elsevier Portugal Universities Nursing Work with us Dfarmacia.Larson MD. Mcdade G. Neurology.com Autors Health Sciences disclaimer Clinical Key Bookstores Register Sciencedirect Distributors Studentconsult © 2013. Medline 40. Medline 39.Larson MD. Boev C..30:409-11. Medline 43. Ozaki M. Sessler DI.51:27-33. Crit Care Med. Effects of reboxetina and desipramine on the kinetics of the pupillary light reflex. Dilated fixed pupils due to administration of high doses of dopamine hydrochloride. Sessler DI. Simulation of cerebral death by succinylcholine sensitivity. depresses the human pupillary light reflex. on human pupillary reflexes during general anesthesia. The diagnosis of brain death.elsevier.77:200-2. Talke P. et-al.7°C with circulatory arrest. Anesthesiology. Karampelas I.. Bjorksten AR. Medline 42. Anesthesiology. Medline 44..90:644-6. Medline Popular searches cocaina chagas troponina comunicacion interauricular atencion primaria riesgo cardiovascular asma guia fibrilacion auricular miopatias inflamatorias guias de practica clinica sindrome metabolico sindrome coronario agudo oftalmologia hipertension pulmonar coartacion aortica insuficiencia mitral hipertension diabetes mellitus diseccion aortica revascularizacion Health Sciences Social Sciences Science and Technology Authors.345:616-7.Thompson AE. 1981.L.38:395-400. Br J Clin Pharmacol. Machinis TG. Medline 47. Quantitative pupillometry: normative data in healthy pediatric volunteers. Arch Dis Child.15:216-7. Fountas KN.Huet R. Medline 49.Grattan-Smith PJ. Medline 48. Basic principles and their application in the non-i.10:384-7. 1999. Medline 45. Resuscitation from accidental hypothermia of 13. Medline 36. Frank JI.17:194-5. J Neurosurg. 2005.Ong L. Dechert M. Larson MD. Anesthesiology.39:251-5. Coad N. 2001.Larson MD.. Arch Neurol. but not mild hypothermia. Anesthesiology. Karliczek G. 1992.Larson MD. http://zl. Intensive Care Med. 1981. The ciliospinal reflex in pentobarbital coma. 1997. Medline 46.69:151-2.79:23-7. J Neurosurg. an adrenoreceptor agonist. Kurz A. 1989. Bruning H. Bretylium intoxication resembling clinical brain death. 1993. Warwick B. Br J Clin Pharmacol.Andrefsky JC. N Engl J Med.


text:
Australian Research Centre for Population Oral Health
CRE in Primary Oral Health Care
Indigenous Oral Health Unit
Nation Dental Telephone Interview Survey
National Study of Adult Oral Health
Oral Health Promotion Clearinghouse
Dentists, specialists and allied practitioners: the Australian dental labour force, 2006
Posted on May 2, 2013 by Jon Saw
The dental labour force comprises dentists, dental specialists and allied practitioners, including dental hygienists, dental therapists, oral health therapists (dual-qualified hygienists and therapists) and dental prosthetists.
The Australian dental labour force in 2006 continued to be dominated by general dental practitioners (67%) and specialists (about 10%). The allied practitioner proportion of 23% was made up of therapists (9%), prosthetists (7%), hygienists (5%) and oral health therapists (2%).
The overall picture is one of small changes in the decade to 2006, with some evidence that the main areas of growth are in the allied practitioner component. Between 2003 and 2006, oral health therapists (OHTs) became much more prominent, a trend that is likely to continue.
There was modest growth in the supply of dentists (including dental specialists) in the decade to 2006, from 46.6 to 50.3 full-time equivalent practising dentists per 100,000 population. Supply was highest in the Australian Capital Territory and lowest in Tasmania and the Northern Territory, with all other States around the national average.
Around 10,400 dentists were practising in Australia in 2006, with four out of every five working in the private sector. The average age of dentists is rising (from 44.4 years to 45.1 years between 2000 and 2006).
Dentists are tending to work slightly fewer hours per week (down from 39.3 hours in 2000 to 38.5 in 2006). This could be the result of an increasing proportion of female dentists in the labour force—female dentists are more likely to work part-time and have career breaks than male dentists. In 2006, about 29% of practising dentists were women.
There were around 1,300 dental specialists in Australia in 2006. Orthodontists were the largest speciality group (39%), followed by oral and maxillofacial surgeons (16%), prosthodontists (13%), periodontists (11%), endodontists (9%) and paediatric dentists (8%).
Capital cities continue to have more dentists per capita than other areas. Between 2003 and 2006, increases in dentist numbers occurred only in Major cities, with falls in Inner regional areas. New dental schools have been established in regional areas aimed at increasing the supply of practitioners there, but the impact of these new schools will not be evident until 2010-15.
There were around 3,100 allied dental practitioners in Australia in 2006. Almost all dental hygienists, dental therapists and oral health therapists were women, while nearly 90% of the 900 or more practising dental prosthetists were men
M Balasubramanian
DN Teusner
AIHW Cat. No. DEN 202
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A clear sky. Low 66F. Winds NNE at 5 to 10 mph..
A clear sky. Low 66F. Winds NNE at 5 to 10 mph.
President Donald Trump spoke about the U.S.-Mexico border during a televised address at 6 p.m. Tuesday, West Coast time. His statements are expected to address the ongoing shutdown of the federal government.
The live-feed of the president's comments from the Oval Office can be viewed on this page.
No, thanks. His false narrative is available 24/7 on social media. Unless and until his addresses are fact-checked in real time, it's a waste of our time - and the American people deserve better.


text:
Greek Immigration Crisis Spawns Shanty Towns and Squats
Greece's inability to tackle a crisis in illegal immigration has left thousands living in shanty towns and squatting in the heart of Athens.
By Nick Squires and Paul Anast in Athens
Published: 7:00AM BST 07 Sep 2009
Tens of thousands of migrants from Africa, Asia and the Middle East attempt to cross by boat to Greece's Aegean islands each year, with many ending up in squalid camps.
Humanitarian groups have condemned the situation as "shocking".
While the country trades on an image of carefree summer holidays, sun-kissed sandy beaches and being the cradle of Western civilization, its picturesque holiday destinations and historic capital have become tainted by the crisis.
Such is the scale of the problem that the country has become Europe's main gateway for illegal immigration, accounting for nearly half of those trying to reach the European Union.
Many migrants try to scrape a living as street hawkers in Greece's big cities before heading to the port of Patras where they seek to smuggle themselves on lorries bound for ferries sailing to Italian ports.
Others have crammed into abandoned buildings in central Athens, just a few blocks from the Acropolis, generating fears of a social crisis as Greece teeters on the brink of recession.
"The Greek capital has become a landfill of human misery and cannot absorb any more illegal immigrants," said Yannis Sgouros, the prefect of Athens.
While the government has ordered raids on the shanty towns and cleared out some occupied buildings in the capital this summer, Greece's failure to tackle the problem sooner has led to a spate of violent attacks against immigrants by hate groups, and a surge of support for an ultranationalist political party.
Its vulnerability to trafficking, due in part to the difficulty of patrolling the seas around its islands, has made it the soft underbelly of Europe for the traffickers and those seeking to make their way to Britain and other western European nations illegally.
In May, riot police had to break up clashes between far-Right extremists who attacked hundreds of North African immigrant squatters living in an old courthouse in the heart of Athens, a few blocks from one of its main squares. Last month police evicted around 600 immigrants from the courthouse.
But a hotel off one of the city's main squares has subsequently been taken over by migrants. The police have admitted that the area had become a nest of drug dealers, prostitutes and petty criminals.
In July the authorities also razed a shanty town in the western port of Patras where hundreds of mostly Afghan migrants lived, hoping to travel by ferry to Italy.
Welfare groups condemned the bulldozing of the camp, which had been constructed from scrap metal and wood and even had its own mosque, as "barbaric". But the port remains a key exit point for migrants hoping to continue their journey westwards and the efforts of the Greek authorities have failed to stop the country being a magnet for those seeking entry to other EU countries.
The main route for immigrants is from neighbouring Turkey in places the two countries are separated by just a mile of open water.
Greece says it detained more than 146,000 illegal immigrants in 2008, a 30 per cent increase from the previous year and 54 per cent up on 2006.
But it now has the highest number of illegal entries each year in the EU, followed by Italy and Spain.
In an attempt to stop clandestine boats from landing on Greek soil, coast guard patrols use radar, satellite navigation, and sophisticated night-vision equipment, backed up by army observation posts on mountain tops.
But even when boat people are detected, they are typically held for several months and then released with a formal order to leave the country in three weeks.
Many end up staying, slipping beneath the authorities' radar and taking casual jobs in a desperate attempt to raise enough money to get to other parts of the EU, often Italy.
Last week the United Nations refugee agency (UNHCR) said its staff were "shocked" at the conditions of a detention centre on the island of Lesbos. UNHCR staff said one room housed over 150 women and 50 babies, many suffering from illness related to the cramped and unsanitary conditions.
"The situation is indicative of broader problems relating to irregular migration and Greece's asylum system," said a UNHCR spokesman in Geneva.
Conditions in official detention centres and makeshift shanty camps are now so bad that some Afghan refugees believe they are better off back in their war-torn country and have agreed to be flown home, said Asan Sukuri, the president of an Afghan community association known.
The Greek government has defended its record, saying it is being overwhelmed by the sheer numbers of migrants and cannot cope.
With 16,000 miles of coastline, authorities say it is impossible to block migrants reaching Greek soil.
Dora Bacoyannis, the foreign minister, said: "The pressure from illegal immigration has become unbearable from the eastern Aegean".
Greek islands struggle with illegal migrants
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Independent Financial Advice - This is where a totally unbiased, whole of market financial adviser reviews your affairs and offers advice across the widest area of your money. They are not tied, linked or restricted to one company, products or services but can offer you are broader solution covering all firms and products. The adviser must quote you a fee for doing the work. This can usually be paid for directly as a fee or via a deduction from your policy or investment charges.
Restricted Financial Advice - This is where a financial adviser may be restricted in what financial advice they offer you. This may be because they are restricted by the number of companies or products that they recommend. For example. they may be an adviser for just one insurance company or a limited range of insurance companies. Alternatively, they may be restricted advisers because they are not qualified or authorised to give advice on all areas of the financial market. A restricted adviser must also quote you a fee for giving advice. The fee can again be paid directly by you or via a deduction from policy of investment charges.
Non Advised Financial Selling - The financial adviser is not a financial adviser. They do not offer or give advice. This is very common for many banks and insurance companies and online investment companies or comparison websites. No financial advice is given or deemed to be given. In many cases, you answer a series of questions and then a few product options are given to you. You choose which policy, mortgage or pension you want. No advice is given. No liability is accepted for you choosing the right or wrong product. No advise sales can still be paid full commission yet you have had no advice. You carry the risk yet you have paid full commission charges. Is it any wonder, given the amount of complaints Banks are receiving that they have adopted this "no advice" model.
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For works where there is the option for fees to be paid from product/policy charges (formerly known as commission), we also give you the option to do this. You can have any fees paid from policy charges. We will advise you if this is wise to do although for most people, we believe you are better off in the longer term getting discount pension and investments and keeping fees separate.
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February 29, 2016 —Open Primaries President John Opdycke appeared on Al Jazeera America with John Seigenthaler to discuss primary election reform and the impact a Top Two primary system will have on our democracy.
it may get more voters out, but on the other hand , it may misinform the way the election may results in November ……..
John looks good. He got the message out loud and clear, that the parties won't Give up the power the people have take it back !


Artificial Intelligence (AI) is a prominent and expanding area of research and innovation. Autonomous machines can decide how to react to the real world and learn from their decisions, software can identify faces in an image of a crowd of people, and smart home devices are able to control aspects of your house after learning patterns from human requests. In recent years, breakthroughs in machine learning using neural networks, which mimic the processes of human neurons, coupled with the availability of near limitless cloud resources have enabled the development of novel AI solutions to previously unsolved problems. Innovators developing AI solutions should consider an intellectual property strategy, including patents to protect their ideas in this growing field.
Our firm assists clients in obtaining, developing, and managing their intellectual property assets in this exciting and rapidly developing area. In addition to holding degrees in computer science, computer and electrical engineering, and physics, many members of our professional staff have earned advanced degrees in these fields.
Our firm has prepared patent applications directed to those areas listed above and more specific examples include disease analysis, drug efficacy prediction, automated medical diagnostics, automated generation of computer source code, product sales prediction, and automation in CAD systems. Our firm represents a client in protecting innovations related to robotics for food processing. For one of our cybersecurity clients, we patent neural network-based technologies for detecting and mitigating phishing attacks.


text:
Q: How to do error accumulation with Cats Effect effects? I've been struggling with error accumulation with effects, and I was wondering what the idiomatic way of modeling this is using Cats Effect.
Without involving effects, I would do something like this:
import cats._
import cats.data._
import cats.implicits._
import cats.effect._

opaque type Version = String
opaque type Path = String
case class ExampleConfig(version: Version, path: Path)

enum ValidationError:
  case InvalidVersion
  case InvalidPath

// Implementation irrelevant to the example
def validateVersion(version: String): ValidatedNec[ValidationError, Version] = ???
def validatePath(path: String): ValidatedNec[ValidationError, Path] = ???

def validateConfig(version: String, path: String): ValidatedNec[ValidationError, ExampleConfig] =
  (validateVersion(version), validatePath(path)).mapN(ExampleConfig.apply)

However, if we now imagine validatePath actually verifies whether the path exists on the filesystem, it becomes an effect like Sync. This makes this case significantly more complex, as we now have:

*

*an additional error channel that we don't want to use, but do need to deal with

*nested types, which quickly become a hassle when mixing effectful and regular validations and when there's dependencies between them, requiring some type juggling

// Implementation irrelevant to the example
def pathExists[F[_]: Sync](path: Path): F[Boolean] = ???

def validatePath2[F[_]: Sync](path: String): F[ValidatedNec[ValidationError, Path]] =
  // Such a dependency between validations leads to major painpoints,
  // as we now have an effect inside a validation, while we would want it the other way around
  validatePath(path)
    .fold(
      e => Sync[F].delay(e.invalid),
      path => Sync[F].ifF(pathExists(path))(path.validNec, ValidationError.InvalidPath.invalidNec)
    )

def validateConfig2[F[_]: Sync](version: String, path: String): F[ValidatedNec[ValidationError, ExampleConfig]] =
  // We now have a distinction between our regular validations, and effectful validations
  val versionValid: ValidatedNec[ValidationError, Version] = validateVersion(version)

  for {
    pathValid: ValidatedNec[ValidationError, Path] <- validatePath2(path)
      // We need to deal with any errors in Syncs error channel,
      // in addition to our validation error domain,
      // as there technically can be additional errors in here that we want to map to validation errors
      .handleError(e => ValidationError.InvalidPath.invalidNec)
  } yield (versionValid, pathValid).mapN(ExampleConfig.apply)

Is there a better, idiomatic, way of modeling error accumulating effect using Cats Effect?

redpajama_set_name: RedPajamaStackExchange


text:
Mobility got restricted in India since the announcement of the lockdown late last month with driving going down by as much as over 80 per cent and walking by 75 per cent in mid-April, according to mobility data trends report from Apple Maps.
When it comes to specific cities, New Delhi recorded 83 per cent reduction in walking on April 13 and 86 per cent reduction in driving on the same day, showed the report which reflects requests for directions in Apple Maps.
(Also read: April could be alarming for Indian auto industry as lockdown extended till May 3)
The restrictions due to Covid-19 had even greater impact in Mumbai where driving got reduced by 89 per cent and walking by 84 per cent on April 13.
The complete data set features daily changes in requests for directions by transportation type for mobility trends for major cities and 63 countries or regions.
The data show change in routing requests from January 13.
The mobility data trends tool from Apple Maps was released on Tuesday to support the impactful work happening around the globe to mitigate the spread of Covid-19.
(Also read: India's petrol, diesel demand slumps 66% in April; ATF down 90% due to lockdown)
Apple hopes that this mobility data may provide helpful insights to local governments and health authorities and may also be used as a foundation for new public policies by showing the change in volume of people driving, walking or taking public transit in their communities.
FILE PHOTO: A man rides past a line of cycles erected across a road, as a blockade, during the nationwide lockdown to slow the spread of the coronavirus disease (COVID-19), in Mumbai. (REUTERS)
Maps does not associate mobility data with a user's Apple ID, and Apple does not keep a history of where a user has been, the company said.
The information is generated by counting the number of requests made to Apple Maps for directions.
The data sets are then compared to reflect a change in volume of people driving, walking or taking public transit around the world.
Data availability in a particular city, country, or region is subject to a number of factors, including minimum thresholds for direction requests made per day, Apple said.
Earlier, Google announced its Community Mobility Reports based on anonymised location data.
These reports from Google chart movement trends over time by geography, across different categories of places such as retail and recreation, groceries and pharmacies, parks, transit stations, workplaces, and residential.
Covid-19coronavirusAppleNational lockdown


text:
<?php namespace Hostbase\ErrorHandling;

use Exception;
use Hostbase\Entity\Exceptions\EntityAlreadyExists;
use Hostbase\Entity\Exceptions\EntityNotFound;
use Hostbase\Entity\Exceptions\InvalidEntity;
use Illuminate\Support\ServiceProvider;
use Request;

/**
 * Class ErrorHandlerServiceProvider
 *
 * @package Hostbase\ErrorHandling
 */
class ErrorHandlerServiceProvider extends ServiceProvider
{
    /**
     * @inheritdoc
     */
    public function register()
    {
        $this->app->error(function(Exception $exception)
        {
            ErrorHandler::logException($exception);
            return ErrorHandler::errorInternalError($exception->getMessage(), (new \ReflectionClass($exception))->getShortName());
        });

        // always return json error response for 404s
        $this->app->missing(function()
        {
            $requestUri = Request::getRequestUri();

            return ErrorHandler::errorNotFound("The request URI '$requestUri' was not found");
        });

        $this->app->error(function(EntityNotFound $exception)
        {
            // todo - evaluate the need for logging 'not found' exceptions
            ErrorHandler::logException($exception);
            return ErrorHandler::errorNotFound($exception->getMessage());
        });

        $this->app->error(function(EntityAlreadyExists $exception)
        {
            ErrorHandler::logException($exception);
            return ErrorHandler::errorConflict($exception->getMessage());
        });

        $this->app->error(function(InvalidEntity $exception) {
            ErrorHandler::logException($exception);
            return ErrorHandler::errorWrongArgs($exception->getMessage());
        });
    }
}

redpajama_set_name: RedPajamaGithub


text:
Fantasy Auto Racing
Raps Over Everything
Scores / Schedule
Tourney Pick'em
Pat Forde
UFC PPV
Carey Price reunites with young fan for emotional NHL Awards moment
Chase Kell
June 19, 2019, 10:57 p.m.
Carey Price presents friend Anderson Whitehead a jersey and a trip to the 2020 NHL All-Star game during the 2019 NHL Awards. (Photo by Ethan Miller/Getty Images)
If you happened to watch the 2019 NHL Awards in Las Vegas, I sure hope you had the tissue box near by.
Shortly after New York Islanders coach Barry Trotz won his second Jack Adams Award, an 11-year-old boy named Anderson Whitehead took the stage for a special presentation.
You may remember Anderson from a video that went viral earlier this year. Following a Montreal Canadiens practice in late February, Anderson got the chance to meet his idol, Carey Price, after his mom had passed away following a battle with cancer. Her dying wish was for her young son one day get to meet his favourite player.
In the video, captured by Anderson's aunt, the young boy is hanging out after when Price takes a moment to meet one of his biggest fans. But this was far from your typical meet-and-greet.
This is everything — this young fan, Anderson, met his idol @CP0031, after his mother passed away due to cancer. She had promised him that she would do everything in her power to help the two meet and it happened. This right here is hockey. #OurGreatGame
(🎥 FB/ Tammy Whitehead) pic.twitter.com/ww6jLM2yoF
— NHL (@NHL) March 1, 2019
Not only did Price take the time to meet his young fan, he also signed two hockey sticks, a mini stick, a puck, and the Price jersey that Anderson had on his back. But the best part of the exchange was the massive hug that Price immediately laid on Anderson when the two crossed paths.
"Words cannot describe how much this meant to Anderson and we are forever grateful to this wonderful man," wrote Anderson's aunt Tammy, in the caption for the video.
Fast forward nearly four months later, as Anderson takes the stage at the NHL Awards along with Sports Illustrated model Camille Kostek.
Kostek begins to tease a surprise for Anderson by explaining that while his favourite player couldn't be there for the big night, Price had prepared a video message for him.
Attention then shifts to the screen, where Price greets Anderson and apologizes for not being able to make the Awards. But the All-Star had a trick up his sleeve.
WHAT A MOMENT!
CAREY PRICE SURPRISES ANDERSON AGAIN ... @CanadiensMTL #NHLAwards pic.twitter.com/LtKWBpeUO1
— Here's Your Replay ⬇ (@HeresYourReplay) June 20, 2019
After a few words on that special moment after practice, Price walks off screen before making an appearance on stage. Anderson quickly sheds a few tears of joy and the entire audience is brought to its feet.
But Price saved the best for last. After gifting Anderson another jersey for the kid's collection, Price asks him if he wants to attend next season's All-Star game.
The answer — a resounding YES — quickly led to a standing ovation in T-Mobile Arena.
If this moment didn't hit you right in the feels, there's likely a cold black hole where your heart should be.
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A.J. Brown has surgery on both knees, says he should have been 'done for the year in like Week 2'
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Ex-Mets GM Jared Porter could be facing an MLB suspension next
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Canadian Nayo Raincock-Ekunwe says she'll skip a second straight WNBA season in order to focus on the Tokyo Olympics. The 29-year-old, a reserve player for the New York Liberty, says she's been in touch with the team and it is aware of her plans to focus on a gold medal. "The plan this year is to forego the WNBA season again and to play with Team Canada for the whole summer, not miss any of our training camps leading up to the Olympics. Fully committed to Team Canada," Raincock-Ekunwe told CBC Sports. Waiting for Raincock-Ekunwe in the WNBA would be a young Liberty team including Canadian teammate Kia Nurse and former No. 1 pick Sabrina Ionescu. The team fielded a league-record seven rookies during its two-win 2020 season. "Of course it's tempting [to play with the Liberty]. I think they're making some moves this year that will be big, that will be beneficial for the team. Sabrina being healthy and with the rookies they had last season getting some experience last year, I think it will be a great year for New York. So yeah, it's tough to turn down the opportunity to play in one of the best leagues in the world. But I think Canada has a really good opportunity this summer," she said. Raincock-Ekunwe currently plays for Lyon of France's Ligue 1, where she intends to finish the season. In some ways, the Penticton, B.C., native's commitment is more crucial in 2021 than it was in 2020. The team meets regularly over Zoom, but hasn't been physically together since last February. An upcoming international window, where European leagues break for national team events, begins Jan. 31, but it's unlikely Canada will meet due to the spread of players across the world and various coronavirus restrictions. One advantage for the Canadians is that most other national teams don't meet virtually nearly as often, according to Raincock-Ekunwe, who previously played at the 2016 Rio Olympics. "I love to represent our country. I love to play with the women on our team. It's like a sisterhood or a family. And it's just such a great thing to be a part of and work together to that one goal. So it's something I look forward to every year getting together with this team. It's been a long time without each other. So it's weird," she said. "I'm really happy that we can just keep the connection through a year of disconnection." Team Canada may not meet in person again until after European league playoffs in May. On Tuesday, Raincock-Ekunwe scored the game-winning basket with 21 seconds remaining in EuroLeague action against Poland's Arka Gdynia. The centre is averaging 12.1 points and 6.3 rebounds on 59 per cent shooting over nine French league games this season, adding 9 points and 7.5 rebounds per game in four EuroLeague contests. Combined, Lyon is 9-4. That low games-played number reflects the bumpy campaign, with a coronavirus outbreak forcing a pause in play at one point. Raincock-Ekunwe was among the players who contracted the virus. "It didn't hit me as hard as some of the others. So I consider myself lucky. But I think I'm back to normal now — normal in this day and age. Honestly, I'm not feeling any side effects. I think right after I got it, it was hard to get the cardio back and kind of get the rhythm back," she said. With the Olympics scheduled to begin in just six months, some of the same virus-related concerns that caused the initial postponement are being brought up once again. As of today, Raincock-Ekunwe says she would support the decision to hold the Games. "I support vaccination and I would hope that there would be enough vaccines for those who would want to have some prior to the Olympics. And I think that could put a lot of people's mind at ease. But I don't think that the athletes should be prioritized over the general population who is at risk," she said. "And maybe I'm biased." After opting out of two straight WNBA seasons, Raincock-Ekunwe has sacrificed more than many potential Olympians. At this point, she just wants to play. "I think we're all ready. Ready to play, ready to represent our countries."
Aaron Rodgers, Patrick Mahomes and Josh Allen have something in common besides being three of the four starting quarterbacks remaining in the NFL playoffs. The three were picked in the first round by teams coming off a playoff berth in moves that Green Bay, Kansas City and Buffalo surely don't regret. The Packers took Aaron Rodgers 24th overall in 2005 despite having Brett Favre on the roster. Favre had led Green Bay to a 10-win season and playoff berth in 2004 and remained the starter for Rodgers' first three seasons. The Packers then made Rodgers the starter in 2008 and have made the playoffs 10 times since then with one Super Bowl title. The Chiefs made their move for a quarterback in 2017 after back-to-back playoff appearances the previous two years with Alex Smith as their starter. Kansas City traded up 17 spots to take Mahomes and gave him the starting role in 2018. All Mahomes has done in that time is win the 2018 MVP award, get named Super Bowl MVP last year and put the Chiefs in position to get back there this season. The pick Kansas City got to take Mahomes came from Buffalo, which ended up with star cornerback Tre'Davious White that season along with extra first- and third-rounders. The Bills then traded up five spots the next year to draft Allen, who has emerged as a star this season. Since 2000, a playoff team has used a first-round pick on a quarterback seven times overall. The Broncos did it twice, taking Jay Cutler in 2006 after making it to the AFC title game with Jake Plummer the previous season, and then Paxton Lynch in 2016 after winning the Super Bowl in Peyton Manning's final season before retirement. The Texans did it in 2017, trading up for Deshaun Watson after making it to the playoffs the previous year with Brock Osweiler, and the Packers did it this past season when they drafted Jordan Love. TOM TERRIFIC: Tom Brady can join some illustrious company with a win this week for another Super Bowl appearance. Brady will appear in his staggering 14th conference title game in 19 seasons as a starter when Tampa Bay visits Green Bay on Sunday. Brady won nine of those previous 13 conference championship games when he was in New England and can become the first football player to appear in 10 NFL title games with a win. Only a handful of players have made it to the championship round 10 times in Major League Baseball or the NBA, including some of the most iconic names in both sports. Yogi Berra has the most with 14 World Series appearances, followed by Mickey Mantle (12), Whitey Ford (11), and Babe Ruth, Joe DiMaggio and Elston Howard (10 each). In the NBA, Bill Russell is the leader with 12 appearances, followed by Celtics teammate Sam Jones with 11. Kareem Abdul-Jabbar and LeBron James each have 10, with James reaching that mark last season. NOT SO SWEET HOME: For the third straight year, the New Orleans Saints' season ended with a playoff loss at home. After dropping the NFC title game to the Rams in the 2018 season thanks in large part to a blown call at the end of regulation, and then losing again in overtime to Minnesota last season, the Saints fell short on Sunday against Tampa Bay after committing four turnovers in a game for the first time since 2016. The Saints became just the third team to lose a home playoff game in three straight seasons, joining Kansas City (2016-18) and Chicago (1986-88). Drew Brees is the only quarterback to do it, as Alex Smith and Patrick Mahomes started the games for the Chiefs, and Doug Flutie and Jim McMahon for the Bears. In all, the Saints have won 49 regular-season games the past four years and don't have a Super Bowl berth to show for it, having also lost in 2017 at Minnesota. That's the most wins ever in a four-year span for a team that didn't make the Super Bowl, according to the Elias Sports Bureau. PLAYING FROM AHEAD: The Chiefs have an impressive streak of holding a lead in 60 straight games in the regular season and playoffs, 10 shy of the record set by Seattle (2012-15). The last team to prevent Kansas City from taking a lead was Buffalo, in a 16-10 win on Nov. 26, 2017. MIGHTY MATT: Packers coach Matt LaFleur is back in the NFC title game for the second time in two seasons as an NFL coach. LaFleur is the sixth coach since the merger to make the conference championship game in his first two seasons and the first to do it since San Francisco's Jim Harbaugh (2011-12). The other coaches to do it are Baltimore's Don McCafferty (1970-71), San Francisco's George Seifert (1989-90), Dallas' Barry Switzer (1994-95) and the Jets' Rex Ryan (2009-10). All those coaches reached at least one Super Bowl in those years with the exception of Ryan, who lost to Indianapolis and Pittsburgh. ___ More AP NFL: https://apnews.com/NFL and https://twitter.com/AP_NFL Josh Dubow, The Associated Press
Chad Henne came off the bench cold in the heat of a tense playoff game and delivered the game-sealing plays for Kansas City in his most consequential performance in a win since 2013. Henne became just the latest understudy quarterback to deliver a memorable performance in the post-season when he relieved an injured Patrick Mahomes and closed out a 22-17 win over Cleveland on Sunday that sent the defending champion Chiefs into the AFC championship game. If Mahomes remains in concussion protocol and can't start this Sunday against the Buffalo Bills, Henne will get the nod as he tries to follow in the footsteps of other playoff fill-ins at quarterback. The most recent success story came three years ago, when Nick Foles replaced an injured Carson Wentz in December and led the Philadelphia Eagles on a magical post-season run that culminated in their only Super Bowl title. Jeff Hostetler blazed a similar path in 1990 with the New York Giants when he took over for an injured Phil Simms late in the season and also won the championship. "Everyone had jumped off the bandwagon," Hostetler recalled three years ago when Foles was making his run. "We were completely shot as a team. That was the outside looking in. Inside where we were at, we just rallied the wagons. It was us versus the world. We just rallied around each other and it showed." There are others as well, including Earl Morrall keeping the 1972 Dolphins perfect long enough for starter Bob Griese to finish the job in the Super Bowl, and Frank Reich staging the epic playoff comeback against Houston 28 years ago while Jim Kelly was out injured. Here's a look at some of the most memorable playoff performances by backup quarterbacks: TOM MATTE: The Baltimore running back was thrust into emergency quarterback duty late in the 1965 season after Johnny Unitas and Gary Cuozzo went down with injuries. Matte started the season finale against the Rams, rushing for 99 yards and throwing two incompletions. He got the nod again the following week in a playoff game against Green Bay with a limited number of plays on a wrist band. He went 5 for 12 for 40 yards and ran for 57 more in a 13-10 loss to the Packers. EARL MORRALL: Morrall was in his 17th season as an NFL journeyman, who had lost to Joe Namath and the Jets in Super Bowl III and was a backup on a champion in Baltimore two years later. He joined the Dolphins in 1972 as Griese's backup on a $100 waiver claim that proved to be a bargain when Griese got hurt in Week 5. Morrall started the next 11 games for the NFL's only perfect team, leading playoff wins over Cleveland and Pittsburgh when he threw a TD pass to Larry Csonka in the AFC title game. Griese returned for the Super Bowl and completed the 17-0 season. JEFF HOSTETLER: Hostetler had started just two games in almost seven full seasons for the Giants when Simms injured his foot in Week 14. After starting that season with 10 straight wins, the Giants lost three out of four and were mostly written off as a contender when Simms got hurt. But Hostetler managed to lead the Giants to two wins to end the regular season, a lopsided playoff opener over Chicago, then upsets over two-time defending champion San Francisco in the NFC title game (15-13 on five field goals) and Buffalo (20-19) in the Super Bowl. He threw three TD passes with no interceptions in the playoff run. FRANK REICH: Two years after losing to Hostetler, the Bills relied on a backup to make it to their third consecutive Super Bowl. Starter Jim Kelly injured his knee in the regular-season finale, forcing Reich to take over in the playoffs. He led an epic comeback from a 35-3 deficit to beat Houston in the wild-card round and then Pittsburgh in the next round, throwing six TD passes with only one INT in the wins. Kelly returned to the AFC title game and started the Super Bowl before getting hurt again in the 52-17 loss to Dallas, which Reich finished. NICK FOLES: Reich was an assistant in Philadelphia 25 years later when Wentz went down with a knee injury that looked like it would derail the Eagles season. Foles stepped in and didn't do much in the final three regular season games and the playoff opener over Atlanta. But he put together one of the greatest two-game stretches in post-season history to deliver the Eagles a title. He threw for 725 yards and six touchdowns in wins over Minnesota in the NFC title game and New England in the Super Bowl. He also caught a TD pass in the 41-33 win against the Patriots on a trick play known as the "Philly Special." ___ More AP NFL: https://apnews.com/NFL and https://twitter.com/AP_NFL Josh Dubow, The Associated Press
With 'no bad options' left in NFL playoffs, ticket prices are rocketing, even during COVID-19 pandemic
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Stadiums light up to join Joe Biden, Kamala Harris in honoring those who died from COVID-19
Stadiums across the country all turned on their lights to honor the more than 400,000 people who have died due to the coronavirus pandemic.
Mad Bets: Daily Best Bets - January 20
Minty Bets, Jared Quay & Matt Gothard give their best bets for Wed. January 20.


text:
Ма́тиши () — населённый пункт в Валмиерском крае Латвии. Административный центр Матишской волости. Находится у перекрёстка региональных автодорог  (Айнажи — Матиши) и  (Валмиера — Матиши — Мазсалаца). Расстояние до города Валмиера составляет около 25 км. По данным на 2015 год, в населённом пункте проживало 486 человек. Есть начальная школа, библиотека, дом культуры, лютеранская церковь.

История
Впервые упоминается в 1678 году, когда здесь была построена церковь (архитектор Руперт Бинденшу).

В советское время населённый пункт был центром Матишского сельсовета Валмиерского района. В селе располагался колхоз «Матиши».

Примечания

Населённые пункты Буртниекского края
Матишская волость
Волостные центры Латвии

redpajama_set_name: RedPajamaWikipedia


I have a portable counter top ice maker, it still freezes but all the parts to hold and move the water/ice are broken.
Does anyone have an idea what I can make with it before I toss it?
Do you like wine? You might be able to make a wine chiller. I'm not completely sure as to the design you would have to go by, but typically they work by filling the box (in your case, the ice maker) with ice and water that is chilled to or below freezing but kept from becoming totally solid by means of an agitator or stirring mechanism.
If you're handy with wiring and basic circuitry, it shouldn't be terribly hard to put together. Just make sure everything is grounded and insulated properly or else your first glass of chilled wine may be more shocking than expected!


text:
Mainly clear. A few flurries or snow showers possible. Low 21F. Winds ENE at 10 to 20 mph..
Mainly clear. A few flurries or snow showers possible. Low 21F. Winds ENE at 10 to 20 mph.
Elder Gerrit W. Gong and his wife, Susan Gong, speak to LDS Young Adults ages 18 to 30 on Sunday and give them three goals for 2021.
Courtesy Intellectual Properties
Helping Hand volunteers ages 18-30 years old in Lima, Peru, helped clear debris in preparation for floors to be installed in people's homes in November 2019. At Sunday's devotional, Elder Gerrit W. Gong listed the many projects that Latter-day Saint young adults are involved in as part of COVID-19 humanitarian relief and in general. "In our day, with immense suffering and humanitarian needs everywhere, we feel compelling cause and divine purpose in offering Christian service," he shared. Jan. 10, 2021.
Elder Gerrit W. Gong gives LDS young adults three goals for 2021
By Genelle Pugmire Daily Herald
Genelle Pugmire
Elder Gerrit W. Gong of the Quorum of the Twelve Apostles of The Church of Jesus Christ of Latter-day Saints extended three invitations Sunday evening to the faith's 2.3 million members between the ages of 18 and 30.
During a special broadcast Sunday, he invited the young adults to first, "Be still and know that God is God."
Gong told them to let God's goodness and creations stir their imagination, calm and assure their heart, and testify God waits ready to deepen their personal relationship with him.
The audience was encouraged to make deliberate attempts to slow down and engage in a more reflective kind of faith life.
"This includes an appreciation for the wonders of the heavens, the beauties of the Earth and the inspirations of art, literature and music," Gong said. "It takes conscious effort to slow down and 'be still.' It takes spiritual openness and humility to 'know that (God is) God (Psalms 46:10)' " he said. "Sometimes slowing down in things that matter less helps us find the things that matter most." Beholding ultimate things fosters an eternal perspective that "can anchor us today," he added.
Second, Gong asked young adults to "change the future now." They can do that by developing "multigenerational relationships that will bless you and those around you for years to come."
"We each look for sociality and opportunities to contribute. We all need a safe place to ask and seek, a safe space to learn and live gospel doctrine and church culture," Gong said.
The apostle said more love and less judgment of others will turn each congregation into a vulnerable and inviting faith community that radiates compassion and inclusivity.
"In divided societies, disciples of Jesus Christ can share a common divinity and humanity greater than any differences," Gong said. "In darkening, sometimes claustrophobic times, believers radiate his light and liberating truth. Where there is spiritual famine in the land, we celebrate him as living water and the bread of life. … Today you help me. Tomorrow I help you. We are here for each other. That's what gospel friends and family do."
Gong's final invitation was for young adults to "trust the Lord of the harvest to help you become a better you."
He referenced a recent church survey that shows the many ways young adult Latter-day Saints are helping to address significant humanitarian needs in their communities around the globe.
For example, Gong said, young adults in the LDS Church and their friends sew masks, support women's refugee centers, clean up after natural disasters, provide nutrition to children, build local communities and donate to food banks.
Gong also listed many humanitarian projects the church is engaged in from COVID-19 response projects to filling food banks around the world with tons of canned food. It has also provided 30 million meals for school children in nine countries.
"As disciples of Jesus Christ, our covenant belonging with God and each other invites us to be good and do good," Gong said.
"As you know, our church provides humanitarian assistance without regard to race, religious affiliation or nationality. Our humanitarian activities are not used to proselyte our beliefs."
Continual engagement in such service, in partnership with God, "will give an abundant increase" in life satisfaction, Gong said, because "(God's) are the blessings of a joy which is full."
Gong also encouraged young adults to qualify for and hold a current temple recommend, volunteer to serve in their local congregations, and "create a personal environment that nurtures faith and helps you keep God's commandments. … Do not let the world pretend to offer you things it cannot deliver."
Sister Susan Gong addressed the topic, "Do Good Now Because Heaven is Not Waiting for the Pandemic to End."
In her remarks Sunday evening, Sister Gong said that increased time at home during the pandemic (in October 2020 she and Elder Gong both had the novel coronavirus) has allowed her to learn the skill of paper piecing. This is a kind of quilting that turns scraps of fabric into intricate designs.
These projects, she said, are counterintuitive because cloth is sewn together upside down and backward from how the final product will appear.
"It's hard to see how these bits of color will resolve into a coherent pattern," she said. "But gradually, as you patiently cut, stitch and press over and over again, a beautiful design emerges."
This, said Susan Gong, is also true of life — especially during a global pandemic now in its 10th month. Though the plan for one's life may be obscured by the fog of difficult circumstances, she encouraged young adults to do good now by developing talents and seeking out wise and righteous mentors.
She encouraged young adults around the world to begin each day with a prayer of gratitude and a sincere plea for chances to serve and grow.
"Then look for opportunities to be a truer friend, a kinder sister, a better son, a more generous neighbor, a more inspired minister, a more patient parent," she said.
"Heaven is not waiting for the pandemic to end, for me to lose 10 pounds or for you to be married to the person of your dreams," she concluded. "Heaven is not waiting for us to be perfect or for us to arrive in the next world to bless us. If we do 'the works of righteousness,' we 'shall receive (our) reward, even peace in this world, and eternal life in the world to come'."
Daily Herald reporter Genelle Pugmire can be contacted at gpugmire@heraldextra.com, (801) 344-2910, Twitter
@gpugmire
Susan Gong
Lds Young Adults
Lds Humanitarian Aid
A 36-year veteran of covering news in Utah County, Genelle covers Provo, Orem, Vineyard, Faith/Religion, including the LDS Church and general assignments.
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madam is this your purse?
This is kinda childish but i have to say something before i die cringing alone. Im really uncomfortable with the Vagisil adverts currently running on UK TV…there i've said it out loud, i don't care, i find the casualness of the whole commercial ridiculous….its not a sanitary product and yet all that is missing from the 30 sec slot is a rollerskating/bike riding montage to accompany the calm voice over detailing the myriad of reasons you might have an itchy fanny, besides thrush! Isn't the name testament enough as to where or why you might need to use Vagisil? It certainly doesn't sound like a beauty product to me…it has that Ronseal does what it says on the packet kind of name. The advert also has me wondering if i would ever appear in a commercial for a feminine product such as this. There's no shame in a bacterial infection (depending on how you got it!), nor in getting paid work but there's one woman like 3 from the front who doesn't look so sure….lol!