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Principal's Messages
From President's Office
Overview April 5, 2018
Focus on Good Neighbor Relations
Jesuit High School has been a proud member of the Carmichael community since its founding in 1963. Established at a time when the surrounding areas were pasture lands and fields, Jesuit is now at the center of a thriving residential neighborhood. In line with our Ignatian tradition, Jesuit continues to be a good neighbor to those who live near us, and this website is an extension of those efforts.
As part of Jesuit's continued focus on good neighbor relations, the Good Neighbor Program was founded to provide open dialogue with our immediate residential community. The Good Neighbor Program can help with problems you might have with our school community, such as parking, litter, or street congestion. As part of our Good Neighbor Program, we also want you to enjoy all that Jesuit has to offer. We invite you to attend a sporting event, play, Mass or one of our many social events. Please check out our school calendar to see what Jesuit High School has to offer, and learn more.
We hope you will help us spread the word about this web page www.jesuithighschool.org/goodneighbor among your neighbors, too.
Event August 16, 2022 - 6:00pm October 11, 2022 - 6:00pm February 9, 2023 - 6:00pm May 2, 2023 - 6:00pm Barry Gym
Good Neighbor Meeting
Quarterly meeting calendar for 22-23 academic year
Neighbors, please join us on campus in the Welcome Center. Please enter through the main gym lobby to access the Welcome Center. More information will be posted as meeting dates approach.
AUGUST 16, 2022 – 6:00PM
OCTOBER 11, 2022 – 6:00PM
FEBRUARY 9, 2023 – 6:00PM
MAY 2, 2023 – 6:00PM
School Resumes August 12
Please note that our first day of instruction is August 12. Drop-off and pick-up locations are the same as the 2021-2022 school year—off American River Drive (only on the school side of the street) and in our main campus lot off O'Donnell and Fair Oaks. No student drop-off on Jacob Lane.
News May 10, 2022
Turf Update
Loyola Field Warranty Replacement Underway
After not having use of home turf for the end of the winter soccer season and all of the spring season, we finally have some great news on the warranty replacement – work is beginning this week. AstroTurf will be on-site starting demolition of the top layer and other work over the next 4-5 weeks to complete the project, which will see a new surface and graphic field design.
Jesuit Stadium Lighting Permitting Process Begins
Dark-Sky Certified Lights to Provide Safe Environment for Players and Spectators
To protect players and spectators and make the best use of school facilities, Jesuit High School has applied to the County of Sacramento seeking approval for a Use Permit Amendment to install state-of-the-art lights in the stadium. The need for lighting has become increasingly evident due to the extreme late summer and fall heat, particularly for football, causing stadium conditions that present significant health risks for players, event participants, and spectators.
The proposed lighting technology eliminates light trespass and has been reviewed and certified by the International Dark-Sky Association to respect neighboring residents. Moreover, with an emphasis on moving our home football games to Friday nights, away from competing weekend daytime campus activities, will relieve traffic and reduce parking intrusion into the surrounding neighborhoods.
Sac County Planning Projects Viewer - Jesuit Stadium Lighting
News April 13, 2022
Stadium Lighting Update
Carmichael/Old Foothill Farms CPAC Meeting to be April 20, 2022
Jesuit High School received notice from the County of Sacramento on the afternoon of Wednesday, April 13, 2022, that the application for Permit Amendment for Stadium Lighting Project will be heard at the following:
Resource May 8, 2019
Good Neighbor Minutes & Agendas
New! Agendas will be posted approximately a week prior to each meeting. Meetings are held quarterly and posted on our school website calendar and the Good Neighbor section.
POSTED HERE Aug 2022 AGENDA
POSTED HERE October 2022 Agenda
Please click on the year to see the pdf of the minutes for each meeting. The meeting date is indicated in parenthesis.
Aug 2022 Minutes (8/16)
Winter 2022 Minutes (2/15)
Spring 2021 Minutes (4/27)
Spring 2021 Minutes (5/4)
*No meetings held in 2020 due to COVID
Spring 2019 Minutes
Fall 2019 Minutes
News August 16, 2021
Dance on Saturday, August 21
Minimal impact on parking, noise expected
Jesuit's annual back-to-school dance, that was originally to be held in the Barry Gym, has been shifted outdoors because of the recently published public health COVID safety guidelines provided to all schools by the county and state.
We want to make you aware that there will be a Freshman/Sophomore Dance Saturday, August 21, 2021, from 7:00 – 10:00 p.m.
Athletic Events on March 20
May notice an increase in traffic and cars in area
Please be aware that there will be several events occurring from 11:00 a.m. to 6:00 p.m., on Saturday, March 20, that may impact traffic in the area. Although we are limiting attendance at these events, you may see more cars than typical in the area. We have reminded all visiting schools and teams to be respectful of our neighbors, and we will strategically place signs as a further reminder to park only in designated areas.
We appreciate your patience as we slowly begin the process of returning to a regular athletic competition schedule.
News June 26, 2020
Alert System Malfunction
Apologies to our neighbors, please disregard false alarms
Jesuit is experiencing a malfunction of its alert system for emergency and lock-down announcements. Those PA announcements were false alarms and should be disregarded.
We apologize for any confusion or inconvenience.
Update on Speaker Relocation
Neighbors, We would like to provide an update to the stadium speaker relocation.
The speakers have been removed from the scoreboard within the 60-day time period directed by the County of Sacramento, and the installation of the wooden poles (on which the speakers will reside) is currently underway. The project is slated for completion by the end of July.
Pod July 28, 2022
View all Good Neighbor Agendas & Minutes
Pod April 29, 2022
Use Permit Amendment Stadium Lighting FAQs
Frequently Asked Questions will be updated as the stadium lighting project progresses
Q: Where can I see a quick summary of what this is about?
A one-sheet summary of Jesuit High School's Use Permit Amendment request to install stadium lighting can be viewed be here. This is an infographic-style flyer to help our community quickly get basic information about the project.
Planning Document from County website - dated 3.03.22
Lighting Project One Sheet and Event Ussage
Heat Monitoring Policy
Keeping students, faculty, athletes, and guests safe
When a high heat advisory has been issued
Jesuit monitors heat carefully throughout the day when temperatures rise. As there are many variables with heat and humidity, we rely on our onsite medical staff and athletic trainers to advise when steps to protect the health and safety of those on the Jesuit Sacramento campus will be necessary.
Stadium Lighting Project
News, updates and information on the proposed lights
Pod February 16, 2022
Join our Good Neighbor email list!
Get notified about Good Neighbor meetings via email. During an emergency such as a power outage or lockdown, we will place pop-up alerts on our home page.
Please share your street address. (Example: 1200 Jacob Lane)
Contact the Good Neighbor Program
Question or concern: *
Use this section to let us know about any issue (noise, tree trimming, litter, parking), to report a problem affecting the entire neighborhood (car break-ins) or to ask a question of Jesuit. Thank you for being our neighbor!
Pod January 28, 2019
What's happening for our Jesuit Sacramento community
Browse the Calendar section for ways to connect and stay engaged. Use the different views to flip between an event list or calendar grid and use the filter tabs to see all the events or reduce the content by topics such as Athletics, Counseling or Schedule. View the full calendar
Sync the school calendar to your personal Google or Apple Calendar! Learn how to subscribe to the most up-to-date version of the calendar on our Communication FAQs.
Weekly Email Update
Jesuit Sacramento's weekly communication to parents and students
Formerly called Staying Connected, this update provides parents, students, faculty, and staff valuable information about happenings at Jesuit High School Sacramento.
We also invite our greater Jesuit Sacramento community to read this newsletter to find out what is happening at 1200 Jacob Lane and to keep in touch with your Marauders.


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This book covers many aspects of the exciting research in mobile robotics. It deals with different aspects of the control problem, especially also under uncertainty and faults. Mechanical design issues are discussed along with new sensor and actuator concepts.


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Nancy Sutley
Senior Assistant General Manager of External and Regulatory Affairs and Chief Sustainability Officer
LADWP
Ms. Sutley was named Chief Sustainability Officer in 2014 and assumed the role of Senior Assistant General Manager of External and Regulatory Affairs in October 2019. Prior to joining the Department, Ms. Sutley served as Chair of the White House Council on Environmental Quality. Under her leadership, the Council played a central role in shepherding the Obama Administration's signature environmental projects and was one of the chief architects of President Obama's 2013 Climate Action Plan. Ms. Sutley has an extensive background in public service that includes posts as Deputy Mayor for Energy and Environment for the City of Los Angeles, Board Member of the Metropolitan Water District, Member of the California State Water Resources Control Board, Energy Advisor for California Governor Gray Davis, Deputy Secretary for Policy and Intergovernmental Relations at the California Environmental Protection Agency, and Senior Policy Advisor for the United States Environmental Protection Agency during the Clinton Administration. Ms. Sutley holds a bachelor's degree from Cornell University and a Master of Public Policy degree from Harvard University.

redpajama_set_name: RedPajamaCommonCrawl


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Long-term outcome of subthalamic nucleus deep brain stimulation for Parkinson's disease using an MRI-guided and MRI-verified approach
Iciar Aviles-Olmos,
Zinovia Kefalopoulou,
Elina Tripoliti,
Joseph Candelario,
Harith Akram,
Irene Martinez-Torres,
Marjan Jahanshahi,
Thomas Foltynie,
Marwan Hariz,
Ludvic Zrinzo,
Patricia Limousin
Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
Correspondence to Professor Patricia Limousin, National Hospital for Neurology and Neurosurgery, Box 146, Queen Square, London WC1N 3BG, UK; p.limousin{at}ucl.ac.uk
Background Subthalamic nucleus (STN) deep brain stimulation (DBS) represents a well-established treatment for patients with advanced Parkinson's disease (PD) insufficiently controlled with medical therapies. This study presents the long-term outcomes of patients with PD treated with STN-DBS using an MRI-guided/MRI-verified approach without microelectrode recording.
Methods A cohort of 41 patients who underwent STN-DBS were followed for a minimum period of 5 years, with a subgroup of 12 patients being followed for 8–11 years. Motor status was evaluated using part III of the Unified Parkinson's Disease Rating Scale (UPDRS-III), in on- and off-medication/on-stimulation conditions. Preoperative and postoperative assessments further included activities of daily living (UPDRS-II), motor complications (UPDRS-IV), neuropsychological and speech assessments, as well as evaluation of quality of life. Active contacts localisation was calculated and compared with clinical outcomes.
Results STN-DBS significantly improved the off-medication UPDRS-III scores, compared with baseline. However, UPDRS scores increased over time after DBS. Dyskinesias, motor fluctuations and demands in dopaminergic medication remained significantly reduced in the long term. Conversely, UPDRS-III on-medication scores deteriorated at 5 and 8 years, mostly driven by axial and bradykinesia subscores. Quality of life, as well as depression and anxiety scores, did not significantly change at long-term follow-up compared with baseline. In our series, severe cognitive decline was observed in 17.1% and 16.7% of the patients at 5 and 8 years respectively.
Conclusions Our data confirm that STN-DBS, using an MRI-guided/MRI-verified technique, remains an effective treatment for motor 'off' symptoms of PD in the long term with low morbidity.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/
http://dx.doi.org/10.1136/jnnp-2013-306907
High-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a well-established surgical treatment for symptoms of Parkinson's disease (PD) insufficiently controlled with medical therapies. In 2005, STN DBS was granted the label of efficacious symptomatic treatment at the Movement Disorder Society (MDS) evidence-based medicine review update of treatments for PD.1 The European Federation of Neurological Societies (EFNS) and MDS—European Section recent collaboration to produce evidence-based recommendations for the treatment of PD accredited DBS with level A evidence for the management of disabling tremor, severe motor complications, unpredictable on–off periods, dyskinesias (including biphasic dyskinesias), off-periods and early-morning dystonia.2 STN DBS has been used for the treatment of patients with PD since the mid-1990s.3 ,4 Short-term and medium-term outcomes are well documented by several studies, showing substantial improvements in motor symptoms and quality of life, and reduction in dopaminergic medication requirements.5–8 Far fewer studies have reported on the effects of microelectrode-guided STN DBS after prolonged follow-up periods.9–11 According to a recent review including STN DBS studies with long-term follow-up data, substantial benefits for some of the motor symptoms, namely, tremor, rigidity, as well as motor complications, were maintained after 5 years.12 However, the same studies noted that akinesia, axial signs and cognition often deteriorated in the long term, most likely in keeping with the natural progression of the disease and the involvement of non-dopaminergic systems.
The major risks associated with the surgical procedure include intracranial bleeding and infection of the implanted material. Microelectrode recording (MER) identifies the neuronal firing patterns of the STN and currently represents the most commonly employed technique to assist and validate target localisation.6 Our group has previously published 12-month safety and efficacy data on a large series of patients with PD (n=79) treated with STN DBS using a standardised surgical technique based on individual MRI-guided and MRI-verified targeting without MER. This approach reduces the number of brain penetrations required and the associated risk of morbidity.13 ,14 Here, we report the long-term outcome in a cohort of individuals who underwent STN DBS at our institution (n=41) and were followed for a minimum period of 5 years, with a subgroup of patients (n=12) being followed for 8–11 years. To our knowledge, this is the first study presenting long-term outcomes of patients treated with high-frequency STN DBS using MRI-guided and MRI-verified approach without MER.
Clinical assessments were done in a non-blinded fashion. All data were prospectively collected and retrospectively analysed.
Forty-five consecutive patients with PD were implanted with bilateral STN DBS electrodes between November 2002 and September 2006 at the National Hospital for Neurology and Neurosurgery. Forty-one patients were followed for at least 5 years and were thus included in the present study. For a subset of 12 of these patients, follow-up data beyond 7 years were available. The remaining four of the initial cohort could not complete 5-year follow-up visits due to death (n=3) or being bed bound following stroke 3 years after surgery (n=1), in all cases unrelated to DBS surgery, and were therefore not included in the present study.
Each patient underwent a multidisciplinary evaluation to decide on the suitability of STN DBS surgery. All patients had a diagnosis of idiopathic PD according to the UK Brain Bank criteria, for at least 5 years, age younger than 70 years, and suffered from disabling motor complications despite optimal medical treatment. A formal levodopa challenge confirmed dopaminergic drug responsiveness. Detailed neuropsychological and neuropsychiatric assessments excluded patients with significant cognitive impairment and/or ongoing psychiatric comorbidities. A structural MRI was obtained to exclude surgical contraindications. Written informed consent was obtained from each patient before surgery. Table 1 summarises the characteristics of patients at baseline.
Characteristics of patients at baseline
Surgical procedure and stimulation programming
Details of our neurosurgical procedure, using an MRI-guided and MRI-verified technique, have been previously described.13 ,15 Briefly, implantation of bilateral quadripolar DBS electrodes (3389 Medtronic, Minneapolis, MN) was performed under local anaesthesia, in the off-medication condition (see below) to allow clinical evaluations during electrode placement. Monopolar stimulation through the contacts of the DBS electrode was sequentially performed to assess for additional therapeutic effects and/or the presence of side effects. One patient did not tolerate the off-medication condition, and surgery was performed under general anaesthesia. The STN was visualised on stereotactic T2-weighted MRI sequences and directly targeted using manual calculation and/or planning software (FrameLink, Medtronic, Minneapolis, Minnesota, USA), without MER. An immediate postoperative stereotactic MRI was performed to verify accurate electrode placement. The pulse generator(s) (Soletra or Kinetra, Medtronic, Minneapolis, Minnesota, USA) was implanted in the subclavicular area and connected subcutaneously to the electrodes under general anaesthesia either immediately or a few days after electrode implantation.
Stimulation was initiated within the first postoperative week, and optimal settings were selected through a screening process. Stimulation and medication were further titrated according to clinical response over subsequent visits.
Clinical assessments
All 41 patients were assessed preoperatively and postoperatively at 1 year (mean±SD 1.1±0.3 years; range 0.8–2 years) and at 5 years (mean±SD 5.2±0.5; range 4.5–6 years). Twelve patients were further assessed at 8 years (mean±SD 8.1±1.6; range 7.2–11 years). Each visit included motor, neuropsychological and speech assessments, as well as evaluation of quality of life, which were carried out the same day or within two consecutive days for each patient.
Motor status was evaluated using part III of the Unified Parkinson's Disease Rating Scale (UPDRS-III). Prior to surgery, patients were assessed in the practically defined 'off state' after overnight withdrawal of antiparkinsonian drugs, and the 'on state', following a levodopa challenge using a suprathreshold dose of oral levodopa. After bilateral STN DBS, motor assessments were sequentially performed at the following conditions, in open fashion: off medication/on stimulation (with stimulation switched on after 12 h medication withdrawal); on medication/on stimulation (1 h after the administration of a suprathreshold dose of levodopa while stimulation was reintroduced). Subscores for individual cardinal features of PD were derived by summation of the relevant items from the UPDRS-III as follows: tremor (items 20–21), rigidity (item 22), bradykinesia (items 23–26, 31) and axial (18, 19, 27–30).
Evaluations also included the UPDRS parts II (activities of daily living (ADL)) and IV (motor complications). UPDRS-IV was divided further into two subscores; items 32–34 to assess dyskinesias and items 35–39 to reflect motor fluctuations (on–off phenomena).
Quality of life was assessed with the Parkinson's Disease Questionnaire 39 (PDQ-39). The 39 items encompass the following domains: mobility, ADL, emotional health, stigma, social support, cognition, communication and bodily discomfort. A summary score from 0 to 100 was calculated for the PDQ-39. This summary index (SI) is the arithmetic mean of the scores for the individual domains.16
Global cognitive functions were tested with the Mattis Dementia Rating Scale (DRS-2). Further analyses were done on the scale components (attention, initiation/perseveration, construction, conceptualisation and memory). The Age-Corrected Mayo's Older Americans Normative Studies (MOANS) Scaled Score (AMSS) was computed from raw total and subscores.17 The test was performed at best clinical condition, under regular medication at baseline, and under current medication and on-stimulation at postoperative follow-ups.
The presence of dementia was clinically defined according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).
The Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) were used to evaluate mood.
Speech was assessed by a speech therapist using the sentence task of the Assessment of Intelligibility for Dysarthric Speech (AIDS); this is the percentage of words correctly understood by a native English speaker blinded to patient status.18
Each patient's medication dose was recorded at each time point, and levodopa equivalent dose (LED) was derived using a standard formula.19
Stimulation settings were documented and the average voltage, pulse width and frequency were calculated for all active contacts for each patient.
Adverse events were systematically documented.
Active contact localisation
Preoperative stereotactic T2-weighted scans were used to visualise the MRI-defined STN in both the axial and the coronal planes. The STN was subdivided into five segments: superior (A), anterior-medial (B), central (C), posterolateral (D) and inferior (E). The stereotactic coordinates of each active contact were calculated from postoperative stereotactic MR images and transposed to the preoperative scan. A functional neurosurgeon, blinded to the clinical outcome, then determined which STN segment the active contact was most closely related to, as previously described.18 The position of each active contact was further classified according to the established functional subsections of the STN.20 ,21 Consequently, contacts associated with A or D segments were considered as stimulating the sensorimotor area of the STN, segment C the associative and in B or E the limbic area of the STN.
Clinical outcomes for continuous values are presented as mean±SD. All numeric values were checked for normality using One-Sample Kolmogorov–Smirnov analysis. Continuous data comparing baseline and postoperative scores were analysed by means of the Student t test, if normally distributed. Alternatively, the Wilcoxon signed-rank test was used for non-parametric data. Differences between independent groups were tested with one-way analysis of variance or the Kruskal–Wallis test, according to data distribution.
Correlations of clinical parameters with motor response to DBS and changes in global cognitive function at 5 and 8 years postoperatively were assessed by Spearman correlation coefficients. Linear regression analysis, as guided by univariate analysis outcome, was used to explore the impact of baseline factors to the abovementioned changes.
The motor response to DBS was calculated as follows: (baseline off-medication score minus postoperative off-medication on-stimulation score)/baseline off-medication score)×100 (positive scores denote improvement).
Change in global cognitive function was calculated as follows: (baseline DSR-2 AMSS minus postoperative DRS-2 AMSS)/baseline DSR-2 AMSS×100 (positive scores denote deterioration).
To allow clinically meaningful comparisons between clinical outcomes controlled by continuous bilateral stimulation, a combined contact score, taking into account both left and right electrodes, was adopted for each patient as follows: (1) both active contacts assigned to the sensorimotor area or one contact assigned to the sensorimotor area and one to the associative; (2) both active contacts assigned to the associative or one to the sensorimotor area and one to the limbic area and (3) both in the limbic area or one in the associative and one in the limbic area of the STN.
All reported p values are two-sided at a significance level of 0.05. All data were analysed using the SPSS statistical package (SPSS, Release V.21.0 Chicago, Illinois, USA).
Motor outcomes
Off medication
STN DBS significantly improved the UPDRS-III score with respect to baseline at all follow-up points. However, an increase in UPDRS scores was observed over time on DBS (table 2, see online supplementary figure). Analysis of UPDRS-III subitems showed that STN DBS provided significant and persistent relief from tremor (72.6% reduction at 1 year, 73.9% at 5 years and 77.2% at 8 years) and rigidity (53.9% reduction at 1 year, 45.2% at 5 years and 50% at 8 years). Significant, but less remarkable, improvements were seen in bradykinesia (45.8% reduction at 1 year, 16.5% at 5 years and 23.2% at 8 years) and axial symptoms by 53.6% at 1 year, 41.2% at 5 years and 21.6% at 8 years. Speech intelligibility significantly deteriorated at 5 (−43.7%) and 8 years (−21.4%).
Effects of STN DBS during the off-medication condition
On medication
UPDRS-III scores during the on-medication–on-stimulation condition did not change significantly at 1 year postoperatively in comparison to baseline. However, deterioration was observed after 5 and 8 years; this was significant at 5 years, but in the smaller sample did not reach significance at 8 years (table 3).
Effects of STN DBS during the on-medication condition
Rigidity subscore was significantly improved at 1 year (28.6%). Tremor and rigidity were improved at 5 years, although this was not significant. On the other hand, both bradykinesia and axial subscores deteriorated significantly at 5 and 8 years. Speech intelligibility declined significantly at 5 (−48.5%) and 8 years (−39.6%).
ADL in the off-medication state (UPDRS-II) improved with DBS at 1, 5 and 8 years. However, ADL scores in the on-medication state did not improve after STN stimulation (tables 2 and 3).
PDQ-39
PDQ-39 SI (score) improved by 26.1% at 1 year (p=0.008), but had almost returned to baseline 5 and 8 years post-DBS (table 4). Improvement in four of the eight PDQ-39 subdomains persisted up to 8 years following surgery: mobility, ADL, stigma and bodily discomfort. However, the support subdomain remained generally unchanged over time. Comparison analyses showed an improvement in bodily discomfort subdomain; but only at 5-year follow-up there was a statistically significant difference (p=0.013). Conversely, emotional well-being and cognition subdomains tended to decline at 5 and 8 years compared with baseline, although this was not significant. Communication was the only subdomain that deteriorated significantly at 5 (p=0.002) and 8 years (p=0.002) in comparison to preoperative mean scores.
STN-DBS effects on PDQ-39 summary index (SI) and different subdomains
Drug-related motor complications
Significant improvements in drug-related motor complications were sustained over time as measured by the subitems of UPDRS-IV. Dyskinesias ameliorated by 50.0% at 1 year, 61.4% at 5 years and 52.3% at 8 years (table 2). On–off motor fluctuations reduced by 51.1% at 1 year, 46.8% at 5 years and 50.0% at 8 years after surgery (table 2).
Neuropsychological evaluations
Results of neuropsychological evaluations are shown in table 5. DRS-2 AMSS scores were stable at 1 year postoperatively, but tended to decline at 5 and 8 years. Nevertheless, p values at 8 years did not reach the chosen level of significance for either total scores or the separate cognitive subdomains. Attention and conceptualisation subscores did not significantly change at 5 years, while initiation/perseveration, construction and memory got significantly worse (table 5).
Dementia as defined by DSM-IV criteria was present in one patient (2.4%) at 1-year post-DBS, seven patients at 5 years (17.1%) and two patients (16.7%) among the ones followed by 8 years. There were no significant changes in BDI and BAI at 5 and 8 years.
Medical treatment, stimulation parameters and device replacements
The mean preoperative LED decreased by 35.4% at 1 year (from 1471.1±515.2 to 949.6±572.7, p<0.001), 45.1% (from 1471.1±515.2 to 668.5±359.3, p<0.001) at 5 years and 48.6% (from 1475±525 to 698.8±541.8, p=0.009) at 8 years. One patient was completely drug-free 1 year after surgery, and remained drug-free after 5 and 8 years.
There were no significant changes in the stimulation amplitude (voltage) from 1 year (3.1±0.7 V) to 5 (3.2±0.7 V) or 8 years (3.11±0.9). Pulse width did not vary significantly over time (1 year 60.4±2.4 µs; 5 years 63.8±12.5 µs and 8 years 61.5±5 µs). The mean stimulation frequency increased slightly but not to a significant degree (1 year 139.5±18.9 Hz; 5 years 142.7±24.1 Hz and 8 years 149.5±14.1 Hz). Bilateral monopolar stimulation was applied in 35 patients (85.4%). Four patients received unilateral double monopolar stimulation (9.7%) and two received bilateral double monopolar stimulation in the 5-year follow-up (4.9%), and one (8.3%) had unilateral double monopolar stimulation in the 8-year follow-up group, and the remaining patients were on bilateral monopolar stimulation.
No implantable pulse generator (IPG) replacement occurred among the patients followed at 5 years. Out of the 12 patients followed in the 8-year group (range 7.2–11 years), two had two IPG replacements and seven had one, under general anaesthesia without complications. The remaining three had no IPG replacements. Bilateral new Soletra IPGs were replaced in one patient and Kinetra IPG in the others, after a mean period of 5.9±1 years.
Active contacts position
At 5 years, 44.1%, 35.3% and 20.6% of active contacts were most closely associated with the motor, associative and limbic regions of the STN, respectively. In the subgroup of patients with 8-year follow–up, 62.5% of active contacts were associated with the motor and 37.5% the associative regions of the STN.
Correlations of clinical outcomes
The magnitude of the motor response to DBS correlated positively with younger age at disease onset (p=0.02). Younger age at surgery demonstrated a non-significant trend towards better motor response to DBS (p=0.07). Worse UPDRS-III off scores at baseline (both total and subscores) and more severe on–off fluctuations also correlated with significantly better postoperative motor responses. Younger age at surgery and better preoperative levodopa responsiveness, as measured by levodopa challenge, showed a positive trend towards a better motor response to DBS (p=0.07 and 0.064). After multivariate regression analysis, only higher tremor subscores in the off condition were found to be an independent factor of better clinical outcome (p=0.001).
Deterioration in DRS-2 scores was associated with older age at baseline, worse motor state in the on condition (UPDRS-III on), worse quality of life at baseline and higher medication requirements as measured by LED. None of the abovementioned factors reached a level of statistical significance when checked in the multivariate analysis.
A better motor outcome was documented when contacts' location calculated score was 1 (= both active contacts assigned to the sensorimotor area of the STN or one contact assigned to the sensorimotor area and one to the associative) in comparison to 2 (= both active contacts assigned to the associative area of the STN or one to the sensorimotor area and one to the limbic area) and 3 (= both in the limbic area or one in the associative and one in the limbic area of the STN). Significantly worse motor outcomes at 5 years were correlated with contact calculated score 3 in comparison to 1 (p=0.046) (figure 1).
Percentage of changes in the Unified Parkinson's disease Rating Scale (UPDRS-III) following subthalamic nucleus (STN) deep brain stimulation (DBS) at 5 years in relation to active contact location calculated score (1=both active contacts assigned to the sensorimotor area of the STN or one contact assigned to the sensorimotor area and one to the associative; 2=both active contacts assigned to the associative area of the STN or one to the sensorimotor area and one to the limbic area; 3=both in the limbic area or one in the associative and one in the limbic area of the STN).
All patients underwent stereotactic MRI immediately after lead implantation. There were no haemorrhages (either symptomatic or asymptomatic). In this group of patients, there were no hardware infections in the primary procedure or at impulse generator replacement. There were no DBS malfunctions, lead fractures or lead migrations. Two patients had their electrodes repositioned due to insufficient response from the first operation.
Five patients had a transient delirium/confusion episode during the first days after surgery. One patient suffered seizures during the 48 h after surgery but did not develop epilepsy. There was no severe depression, suicide or attempted suicide. There were four cases of impulse control disorder likely drug related, occurring at least 1 year after surgery, and one case of hypomania that required hospital admission.
We report a long-term follow-up evaluation of the effect of high-frequency STN DBS in patients with advanced PD, who were operated on using a MRI-guided and MRI-verified approach without MER. Beneficial antiparkinsonian effects of DBS on rigidity and tremor in the off-medication state persisted after a follow-up period of 5 and 8 years. Improvements on dyskinesias and motor fluctuations also persisted in the long term.
Motor scores
In our series, the motor scores in the 'off-medication' state assessed by UPDRS-III were significantly reduced by stimulation, leading to an amelioration of the frequency and severity of 'off' periods that remained significantly improved in the long term. Comparison of the UPDRS-III scores in the 'off' medication state obtained at baseline with the one at 5 and 8 years in the 'off' medication and on stimulation condition revealed sustained improvement, as has been previously reported.10 ,22 ,23 On the other hand, UPDRS-III on medication significantly deteriorated at 5 and 8 years, mostly driven by axial symptoms and bradykinesia subscores.9 ,23 This outcome was paralleled by deterioration in the ability to perform daily living activities measured by UPDRS-II 'on medication'. As previously reported, the deterioration in axial symptoms, for example, speech and postural instability, is characteristic of the natural history of PD, likely due to non-dopaminergic deficits.9
Reduction of dopaminergic therapy responsiveness, a well-recognised feature of advanced PD, combined with extension of the PD pathological process beyond the nigro-striatal dopaminergic system, could be partially responsible for this decline in the long-term response to DBS during the on-medication condition.24 ,25 Whether the longer-term deterioration of gait and balance merely reflects disease progression or is partially caused by chronic high-frequency STN DBS merits further investigation.
Our series demonstrated a positive correlation between younger age at PD onset and better long-term motor outcome after STN DBS. However, shorter disease duration or younger age at surgery did not seem to favourably impact the long-term motor response to DBS, although a trend was noted for younger age. It has been shown that younger age at onset is generally associated with a slower disease progression, likely in keeping with higher prevalence of some genetic forms of PD.26
As previously reported, delayed deterioration in speech can occur following STN DBS.9 ,18 Indeed, a decline in speech intelligibility was observed in this cohort, both during off-medication and on-medication conditions. Interestingly, this deterioration was more pronounced during the on-medication condition in comparison to the off-medication condition.
Cognitive scores
The proportion of patients with severe cognitive decline in our series was 17.1% at 5 years and was remarkably similar (16.7%) at 8 years. These rates are relatively lower in comparison to what has been previously reported (43% in a cohort of patients followed up >7 years after bilateral STN DBS).22 However, the cohort of patients described by these authors had higher age at surgery (61.5±5.7 vs 52.8±10.1 in our 8-year group) and longer disease duration at STN DBS implantation (22.8±2.3 vs 12.3±4 in our group). Nevertheless, a multicentre study that followed 35 STN DBS patients (mean disease duration at surgery 13.5 years, and mean age at surgery 59.6) for 5–6 years reported cognitive decline in 22.8%, a figure that is closer to that found in our series.23
A number of studies have reported on health-related quality of life after STN DBS showing favourable outcomes over short-term follow-up.27–30 To our knowledge, this series is the first to report long-term follow-up of quality of life in patients with PD treated with STN DBS.
In keeping with previously published data, health-related quality of life measured by PDQ-39 was significantly improved after STN-DBS in 1 year in our series. Total PDQ-39 scores have returned to baseline levels, although remained slightly better, at 5- and 8-year follow-up. Subdomains such as mobility, ADL, stigma, support and bodily discomfort were the ones showing a more sustained improvement over time. Conversely, emotional well-being, cognition and communication subdomains declined at 5 and 8 years.
The development of non-levodopa-responsive features could be, at least partially, responsible for the decline in quality of life from 1 year to 5- and 8-year follow-up in our series.
It has been suggested that STN DBS may have an antidepressant effect in PD over time.31 Although higher levels of transient depressive disorders have been reported after the intervention,32 especially in the short term, it is mostly reported that depression and anxiety tend to improve in the first years after STN DBS.33 Nonetheless, depression and anxiety scores tend to reach baseline levels in studies reporting longer follow-up results. Accordingly, in our cohort, there was no significant change in depression or anxiety at long-term follow-up relative to baseline.
MRI-guided and MRI-verified DBS
The low morbidity of the MRI-guided and MRI-verified approach to surgery employed in this series demonstrates a high standard of safety while maintaining therapeutic efficacy.34 We are not aware of any other report on the long-term follow-up of patients with PD who had surgery with MRI-guided and MRI-verified STN DBS without use of MER. The optimal target point within the visualised STN is still disputed.35 Initially, we targeted the centre of the visualised STN as described by Bejjani et al.36 Ongoing audit of lead location and associated clinical results eventually resulted in the intended target point being located 2 or 3 mm posterolateral to that described by Bejjani. Thus, we currently target the most superior, posterior and lateral portion of the nucleus, thought to be the sensorimotor STN.20 ,21 These areas are equivalent to those labelled 1 and 2. Our data suggest that there is a significant correlation between lead location associated with these regions of the STN and superior improvement in motor outcomes. Other authors have reported that lead location in relation to the STN on postoperative imaging can predict clinical outcome.37 ,38 Our findings extend this concept to long-term clinical outcome.
The risk of symptomatic haemorrhage inevitably rises with increasing numbers of micro-electrode or macro-electrode brain penetrations. MRI-guided and MRI-verified surgery has been associated with a significantly reduced risk of haemorrhagic complications in functional neurosurgery.34 Accordingly, none of the patients in this series had visible haemorrhage on their postoperative imaging, confirming that a meticulous approach to MRI-guided and MRI-verified DBS is safe and accurate, with clinical outcomes comparable to other techniques, yet with a reduced risk associated with surgery.
Despite the lack of double-blind assessments and the relatively small sample size, our results suggest that motor improvements following STN DBS can be sustained beyond 8 years.
We would like to thank Professor Lisa Cipolotti, Dr Priyanka Pradhan and the neuropsychology department, as well as Dr Leonora Wilkinson and Dr Donna Page, for contribution to the cognitive data; and Dr Steve Tisch, Dr Paul Silberstein, Dr Raul Martinez-Fernandez, Dr Etienne Holl, Dr Erika Petersen and Ellie Borrell for contribution to clinical and imaging data. Finally, we wish to thank the patients and their families, without whose support none of this research would have been possible.
Goetz CG,
Poewe W,
Rascol O,
. Evidence-based medical review update: pharmacological and surgical treatments of Parkinson's disease: 2001 to 2004. Mov Disord 2005;20:523–39.
Ferreira JJ,
Katzenschlager R,
Bloem BR,
. Summary of the recommendations of the EFNS/MDS-ES review on therapeutic management of Parkinson's disease. Eur J Neurol 2013;20:5–15.
Limousin P,
Pollak P,
Benazzouz A,
. Effect of parkinsonian signs and symptoms of bilateral subthalamic nucleus stimulation. Lancet 1995;345:91–5.
Krack P,
. Electrical stimulation of the subthalamic nucleus in advanced Parkinson's disease. N Eng J Med 1998;339:1105–11.
Kleiner-Fisman G,
Herzog J,
Fisman DN,
. Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord 2006;21(Suppl 1):S290–304.
Weaver FM,
Follett K,
Stern M,
. Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA 2009;301:63–73.
Williams A,
Gill S,
Varma T,
. Deep brain stimulation plus best medical therapy versus best medical therapy alone for advanced Parkinson's disease (PD SURG trial): a randomised, open-label trial. Lancet 2010;9:581–91.
Deuschl G,
Schade-Brittinger C,
. A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med 2006;355:896–908.
Batir A,
Van Blercom N,
. Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson's disease. N Engl J Med 2003;349:1925–34.
Fasano A,
Romito LM,
Daniele A,
. Motor and cognitive outcome in patients with Parkinson's disease 8 years after subthalamic implants. Brain 2010;133:2664–76.
Castrioto A,
Lozano AM,
Poon Y-Y,
. Ten-year outcome of subthalamic stimulation in Parkinson disease: a blinded evaluation. Arch neurol 2011;68:1550–6.
Rodriguez-Oroz MC,
Moro E,
Krack P
. Long-term outcomes of surgical therapies for Parkinson's disease. Mov Disord 2012;27:1718–28.
Foltynie T,
Zrinzo L,
Martinez-Torres I,
. MRI-guided STN DBS in Parkinson's disease without microelectrode recording: efficacy and safety. JNNP 2011;82:358–63.
. Reducing hemorrhagic complications in functional neurosurgery: a large case series and systematic literature review. J Neurosurg 2012;116:84–94.
Holl EM,
Petersen EA,
. Improving targeting in image-guided frame-based deep brain stimulation. Neurosurgery 2010;67:437–47.
Jenkinson C,
Fitzpatrick R,
Peto V,
. The Parkinson's Disease Questionnaire (PDQ-39): development and validation of a Parkinson's disease summary index score. Age Ageing 1997;26:353–7.
Lucas JA,
Ivnik RJ,
Smith GE,
. Normative data for the Mattis Dementia Rating Scale. J Clin Exp Neuropsychol 1998;20:536–47.
Tripoliti E,
. Effects of subthalamic stimulation on speech of consecutive patients with Parkinson disease. Neurology 2011;76:80–6.
Williams-Gray CH,
Brayne CEG,
. Evolution of cognitive dysfunction in an incident Parkinson's disease cohort. Brain 2007;130:1787–98.
Yelnik J,
Bardinet E,
Dormont D,
. A three-dimensional, histological and deformable atlas of the human basal ganglia. I. Atlas construction based on immunohistochemical and MRI data. NeuroImage 2007;34:618–38.
Lambert C,
Nagy Z,
. Confirmation of functional zones within the human subthalamic nucleus: patterns of connectivity and sub-parcellation using diffusion weighted imaging. NeuroImage 2012;60:83–94.
Merola A,
Zibetti M,
Angrisano S,
. Parkinson's disease progression at 30 years: a study of subthalamic deep brain-stimulated patients. Brain 2011;134:2074–84.
. Long-term results of a multicenter study of subthalamic and pallidal stimulation in Parkinson's disease. Mov Disord 2010;25:578–86.
Müller J,
Wenning GK,
Jellinger K,
. Progression of Hoehn and Yahr stages in Parkinsonian disorders: a clinicopathologic study. Neurology 2000;55:888–91.
Lang AE,
Obeso JA
. Challenges in Parkinson's disease: restoration of the nigrostriatal dopamine system is not enough. Lancet Neurol 2004;3:309–16.
Schrag A,
Ben-Shlomo Y,
Brown R,
. Young-onset Parkinson's disease revisited--clinical features, natural history, and mortality. Mov Disord 1998;13:885–94.
LaGrange E,
. Bilateral subthalamic nucleus stimulation improves health-related quality of life in PD. Neurology 2002;59:1976–8.
Martinez-Martin P,
Valldeoriola F,
Tolosa E,
. Bilateral subthalamic nucleus stimulation and quality of life in advanced Parkinson's disease. Mov Disord 2002;17:372–7.
Siderowf A,
Jaggi JL,
Xie SX,
. Long-term effects of bilateral subthalamic nucleus stimulation on health-related quality of life in advanced Parkinson's disease. Mov Disord 2006;21:746–53.
Witt K,
Daniels C,
Reiff J,
. Neuropsychological and psychiatric changes after deep brain stimulation for Parkinson's disease: a randomised, multicentre study. Lancet Neurol 2008;7:605–14.
Takeshita S,
Kurisu K,
Trop L,
. Effect of subthalamic stimulation on mood state in Parkinson's disease: evaluation of previous facts and problems. Neurosurg Rev 2005;28:179–86; discussion 187.
Houeto JL,
Mesnage V,
Mallet L,
. Behavioural disorders, Parkinson's disease and subthalamic stimulation. JNNP 2002;72:701–7.
Castelli L,
Perozzo P,
. Chronic deep brain stimulation of the subthalamic nucleus for Parkinson's disease: effects on cognition, mood, anxiety and personality traits. Eur Neurol 2006;55:136–44.
. Image-verified deep brain stimulation reduces risk and cost with no apparent impact on efficacy. Mov Disord 2012;27:1585–6; author reply 1586–7.
Coenen VA,
Prescher A,
Schmidt T,
. What is dorso-lateral in the subthalamic Nucleus (STN)?--a topographic and anatomical consideration on the ambiguous description of today's primary target for deep brain stimulation (DBS) surgery. Acta Neurochir (Wien) 2008;150:1163–5; discussion 1165.
Bejjani BP,
Pidoux B,
. Bilateral subthalamic stimulation for Parkinson's disease by using three-dimensional stereotactic magnetic resonance imaging and electrophysiological guidance. J Neurosurg 2000;92:615–25.
Paek SH,
Yun JY,
Song SW,
. The clinical impact of precise electrode positioning in STN DBS on three-year outcomes. J Neurol Sci 2013;327:25–31.
Wodarg F,
Reese R,
. Stimulation site within the MRI-defined STN predicts postoperative motor outcome. Mov Disord 2012;27:874–9.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
Data supplement 1 - Online supplement
IA-O, ZK, LZ and PL contributed equally to this study.
Contributors IA-O and ZK made equal contributions in analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published. ET, JC, HA, IM-T and MJ were responsible for data collection and final approval of the version to be published. TF and MH were responsible for data collection, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published. LZ and PL were responsible for conception and design, data collection, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published.
Funding This work was undertaken at UCL/UCLH and was funded in part by the Department of Health NIHR Biomedical Research Centres funding scheme. The Unit of Functional Neurosurgery, UCL Institute of Neurology, Queen Square, London, is supported by the Parkinson's Appeal and the Sainsbury's Monument Trust.
Competing interests None.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/


text:
Valentines ist eine Ortschaft in Uruguay.

Geographie

Lage
Sie befindet sich auf dem Gebiet der Departamentos Treinta y Tres und Florida in deren Sektoren 6 und 4 in der Cuchilla Grande. Nächstgelegene Ansiedlungen auf floridanischem Departamentogebiet sind jeweils einige Kilometer nördlich Cerro Chato und Nico Pérez im Süden.

Bodenschätze
Bei Valentines existieren Eisenerz-Vorkommen.

Einwohner
Valentines hatte bei der Volkszählung im Jahre 2011 178 Einwohner, davon 133 Einwohner (71 männliche und 62 weibliche) im Departamento Treinta y Tres und 45 (22 männliche und 23 weibliche) in Florida. 2004 waren es noch 217 Einwohner, davon 178 im Departamento Treinta y Tres und 39 in Florida.

Quelle: Instituto Nacional de Estadística de Uruguay

Weblinks
 Stadtplan von Valentines (PDF; 86 kB)

Einzelnachweise

Ort im Departamento Florida
Ort im Departamento Treinta y Tres

redpajama_set_name: RedPajamaWikipedia


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Dead Cells, the beloved fast-paced roguelike that came out last year, has sold over one million copies to date.
The news comes out of a GDC talk, which was reported on by US Gamer. Motion Twin game designer Sébastien Bénard told the audience that 60 percent of those sales are accounting PC, with Switch being the bestselling platform for consoles.
Dead Cells is available on Switch, PS4, Xbox One, and PC.
For more, read our review of Dead Cells, as well as our in-depth interview with Bénard about scrapped ideas, the potential for a sequel, and more.


What MLP character are you?
Ever wondered which MLP character you're the most like? Wonder no more! This quiz will show you once and for all which of the mane six you are!!
Are you the gentle Futtershy? The fashionable Rarity? Or the awesome Rainbow Dash? So many questions, and only one way to answer them. And who knows? Maybe I made some sort of an "easter egg" as well.
A friend invites you to a party, but you don't know anyone else who'll be there. What do you say?
A PARTY!? Of course I'll come!
Umm..No, that's all right. Thanks for asking.
Yeah I'll be there, I can make some new friends there!
I'm afraid I'm busy that evening, sorry.
Sure, can I bring some of my other friends?
Are you a dependable person?
Of course! I never leave my friends hanging!
I can't say that I am no.
Yeah, I always help my friends.
I think most people know that they can trust me yeah.
To work hard and to help as many people as possible!
To have fun with friends!
To achieve your dreams of course!
To learn as much as possible.
To help out any people or animals in need.
Well yeah! There more the merrier!
Not really, I prefer peace and quiet.
I can't learn about friendship without friends.
No, I just sit in a dark corner all day.
Yes! I love other people!
I don't mind other people as long as they have class.
If you were to make a song. What would it be about?
I'm not much of a singer to be honest.
I'd sing about designing dresses.
Maybe about animals or something?
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In a bustling city with a lot of shops!
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I don't have any pets, just animal friends.
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Not intentionally, but I sometimes become the "leader" without wanting to.
Oh once or twice, not that often though.
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Not really, I'm mostly in the background.
Heads, tails, arms or legs?
...Are you trying to be funny or something?
Last question. Was this a good quiz?
Wich Pony Are You? by S.E.
Quiz topic: What MLP character am I?


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A close look at the state of negotiations between India and United States on the implementation of last July's Indo-U.S. nuclear deal suggests things are not going as smoothly as the two governments are suggesting. In particular, Washington is refusing to accept New Delhi's stand that its indigenous fast breeder programme will not be subjected to IAEA inspections.
As India and the United States concluded their third round of technical talks on the planned separation and safeguarding of Indian civilian nuclear facilities this week, the status of the country's fast breeder programme is emerging as a key obstacle to the conclusion of an agreement acceptable to both sides, The Hindu has learnt.
According to sources familiar with the ideas exchanged by both delegations, the U.S. team, headed by Under-Secretary of State for Political Affairs Nicholas Burns, is unwilling to accept India's position that the fast breeder, as an R&D programme, will not be put on the list of civilian facilities that are offered up for safeguards and inspections by the International Atomic Energy Agency (IAEA).
The American delegation is understood to have argued that there was nothing unique or distinctive about the fast breeder technology, which warranted an exception being made for it. They argued that if Japan could agree to subject its Joyo experimental breeder reactor and Monju prototype reactor to IAEA safeguards, there was no reason why India could not.
Both reactors have been under safeguards since their inception and today are subject to full-time advanced verification systems such as `neutron coincidence counters', radiation monitoring systems and fuel flow monitors, in addition to video surveillance. If India does not accept safeguards on its breeders, the U.S. argues, it will be very hard to get the Nuclear Suppliers Group (NSG) to sign off on a rule change enabling nuclear commerce with India.
Thursday's meeting here was apparently the first time the Indian side formally got to learn of America's insistence on safeguarding the 20-year old Fast Breeder Test Reactor (FBTR) and Prototype Fast Breeder Reactor (PFBR) at Kalpakkam, near Chennai. Even as recently as December last, following the conclusion of the second round of talks, well-placed Indian officials told The Hindu that the breeder issue had never been raised by the American side.
At Thursday's discussions, however, the Japanese analogy for safeguards cut no ice. The Indian side pointed out that there was no basis to compare India with Japan when the July 18, 2005 agreement spoke of India assuming "the same responsibilities and practices and (acquiring) the same benefits and advantages as other leading countries with advanced nuclear technology, such as the United States." Japan was a non-nuclear weapon state under the NPT and the status of its safeguards agreement with the IAEA had no bearing on what India should do.
India also believes that the breeder technology plays a much less important part in Japan's overall nuclear energy mix than it does in Indian plans. Unlike the Japan Atomic Energy Agency, which has the freedom to source components and technology from any part of the world, India's Department of Atomic Energy has had to rely on its own resources and technologies.
Allowing IAEA inspections will seriously compromise the quality and scope of ongoing research, nuclear scientists who have worked closely on and led the breeder programme told The Hindu .
At the heart of the U.S. insistence on safeguarding the fast breeders is its reluctance to accept India as a nuclear weapons state, scientists familiar with the programme's potential weapons application say. Though India wants breeders for civilian purposes, a breeder reactor can also be used as a "laundry" to breed weapon-grade Pu-239 from reactor grade plutonium (Pu-240) generated by pressurised heavy water reactors (PHWRs). Placing the breeder programme under safeguards, then, ensures that the reactors are never used as a "laundry", effectively limiting India's ability to produce fissile material through this route.
Though the breeder programme has emerged as a potentially intractable issue, news from the technical talks was not all bleak. There was some forward movement on the question of CIRUS, the Canadian supplied 40 MW research reactor which has been a mainstay of the Indian nuclear weapons programme despite a `peaceful use only' pledge at the time of its purchase. The American side has given ample indication of its willingness to let bygones be bygones, provided India is also able to convince Canada about the reactor's final disposition.
One of the arguments the American side must contend with is that if India is forced to convert CIRUS to a purely civilian facility, its strategic programme would likely require the construction of a brand new research reactor whose capacity — i.e. throughput of fissile material — would probably be more than 40 MW because of economies of scale.
All told, the prospects of a substantial agreement on separation and safeguards being reached before the visit to India of President George W. Bush look slim, though Indian and U.S. officials continue to insist this is the deadline they are working towards. With Prime Minister Manmohan Singh likely to visit Washington in 2007, however, there is already talk of next year being a more realistic timeframe for resolving outstanding issues.


text:
Mammoth is designed to convert .docx documents,
such as those created by Microsoft Word, Google Docs and LibreOffice,
and convert them to HTML.
Mammoth aims to produce simple and clean HTML by using semantic information in the document,
and ignoring other details.
For instance,
Mammoth converts any paragraph with the style `Heading 1` to `h1` elements,
rather than attempting to exactly copy the styling (font, text size, colour, etc.) of the heading.

There's a large mismatch between the structure used by .docx and the structure of HTML,
meaning that the conversion is unlikely to be perfect for more complicated documents.
Mammoth works best if you only use styles to semantically mark up your document.

The following features are currently supported:

* Headings.

* Lists.

* Customisable mapping from your own docx styles to HTML.
  For instance, you could convert `WarningHeading` to `h1.warning` by providing an appropriate style mapping.

* Tables.
  The formatting of the table itself, such as borders, is currently ignored,
  but the formatting of the text is treated the same as in the rest of the document.

* Footnotes and endnotes.

* Images.

* Bold, italics, underlines, strikethrough, superscript and subscript.

* Links.

* Line breaks.

* Text boxes. The contents of the text box are treated as a separate paragraph
  that appears after the paragraph containing the text box.

* Comments.

## Installation

Available on [Maven Central](http://search.maven.org/#artifactdetails|org.zwobble.mammoth|mammoth|1.5.0|jar).

```xml
<dependency>
  <groupId>org.zwobble.mammoth</groupId>
  <artifactId>mammoth</artifactId>
  <version>1.5.0</version>
</dependency>
```

## Other supported platforms

* [JavaScript](https://github.com/mwilliamson/mammoth.js), both the browser and node.js.
  Available [on npm](https://www.npmjs.com/package/mammoth).

* [Python](https://github.com/mwilliamson/python-mammoth).
  Available [on PyPI](https://pypi.python.org/pypi/mammoth).

* [WordPress](https://wordpress.org/plugins/mammoth-docx-converter/).

* [.NET](https://github.com/mwilliamson/dotnet-mammoth).
  Available [on NuGet](https://www.nuget.org/packages/Mammoth/).

## Usage

### Library

#### Basic conversion

To convert an existing .docx file to HTML,
create an instance of `DocumentConverter` and
pass an instance of `File` to `convertToHtml`.
For instance:

```java
import org.zwobble.mammoth.DocumentConverter;
import org.zwobble.mammoth.Result;

DocumentConverter converter = new DocumentConverter();
Result<String> result = converter.convertToHtml(new File("document.docx"));
String html = result.getValue(); // The generated HTML
Set<String> warnings = result.getWarnings(); // Any warnings during conversion
```

You can also extract the raw text of the document by using `extractRawText`.
This will ignore all formatting in the document.
Each paragraph is followed by two newlines.

```java
DocumentConverter converter = new DocumentConverter();
Result<String> result = converter.extractRawText(new File("document.docx"));
String html = result.getValue(); // The raw text
Set<String> warnings = result.getWarnings(); // Any warnings during conversion
```

#### Custom style map

By default,
Mammoth maps some common .docx styles to HTML elements.
For instance,
a paragraph with the style name `Heading 1` is converted to a `h1` element.
You can add custom style maps by calling `addStyleMap(String)`.
A description of the syntax for style maps can be found in the section ["Writing style maps"](#writing-style-maps).
For instance, if paragraphs with the style name `Section Title` should be converted to `h1` elements,
and paragraphs with the style name `Subsection Title` should be converted to `h2` elements:

```java
DocumentConverter converter = new DocumentConverter()
    .addStyleMap("p[style-name='Section Title'] => h1:fresh")
    .addStyleMap("p[style-name='Subsection Title'] => h2:fresh");
```

You can also pass in the entire style map as a single string,
which can be useful if style maps are stored in text files:

```java
String styleMap =
    "p[style-name='Section Title'] => h1:fresh\n" +
    "p[style-name='Subsection Title'] => h2:fresh";
DocumentConverter converter = new DocumentConverter()
    .addStyleMap(styleMap);
```

The most recently-added styles have the greatest precedence.
User-defined style mappings are used in preference to the default style mappings.
To stop using the default style mappings altogether,
call `disableDefaultStyleMap`:

```java
DocumentConverter converter = new DocumentConverter()
    .disableDefaultStyleMap();
```

#### Custom image handlers

By default, images are converted to `<img>` elements with the source included inline in the `src` attribute.
This behaviour can be changed by calling `imageConverter()` with an [image converter](#image-converters) .

For instance, the following would replicate the default behaviour:

```java
DocumentConverter converter = new DocumentConverter()
    .imageConverter(image -> {
        String base64 = streamToBase64(image::getInputStream);
        String src = "data:" + image.getContentType() + ";base64," + base64;
        Map<String, String> attributes = new HashMap<>();
        attributes.put("src", src);
        return attributes;
    });
```

where `streamToBase64` is a function that reads an input stream and encodes it as a Base64 string.

#### Bold

By default, bold text is wrapped in `<strong>` tags.
This behaviour can be changed by adding a style mapping for `b`.
For instance, to wrap bold text in `<em>` tags:

```java
DocumentConverter converter = new DocumentConverter()
    .addStyleMap("b => em");
```

#### Italic

By default, italic text is wrapped in `<em>` tags.
This behaviour can be changed by adding a style mapping for `i`.
For instance, to wrap italic text in `<strong>` tags:

```java
DocumentConverter converter = new DocumentConverter()
    .addStyleMap("i => strong");
```

#### Underline

By default, the underlining of any text is ignored since underlining can be confused with links in HTML documents.
This behaviour can be changed by adding a style mapping for `u`.
For instance, suppose that a source document uses underlining for emphasis.
The following will wrap any explicitly underlined source text in `<em>` tags:

```java
DocumentConverter converter = new DocumentConverter()
    .addStyleMap("u => em");
```

#### Strikethrough

By default, strikethrough text is wrapped in `<s>` tags.
This behaviour can be changed by adding a style mapping for `strike`.
For instance, to wrap strikethrough text in `<del>` tags:

```java
DocumentConverter converter = new DocumentConverter()
    .addStyleMap("strike => del");
```

#### Comments

By default, comments are ignored.
To include comments in the generated HTML,
add a style mapping for `comment-reference`.
For instance:

```java
DocumentConverter converter = new DocumentConverter()
    .addStyleMap("comment-reference => sup");
```

Comments will be appended to the end of the document,
with links to the comments wrapped using the specified style mapping.

### API

#### `DocumentConverter`

Methods:

* `Result<String> convertToHtml(File file)`: converts `file` into an HTML string.

* `Result<String> convertToHtml(InputStream stream)`: converts `stream` into an HTML string.
  Note that using this method instead of `convertToHtml(File file)` means that relative paths
  to other files, such as images, cannot be resolved.

* `Result<String> extractRawText(File file)`:
  extract the raw text of the document.
  This will ignore all formatting in the document.
  Each paragraph is followed by two newlines.

* `Result<String> extractRawText(InputStream stream)`:
  extract the raw text of the document.
  This will ignore all formatting in the document.
  Each paragraph is followed by two newlines.

* `DocumentConverter addStyleMap(String styleMap)`:
  add a style map to specify the mapping of Word styles to HTML.
  The most recently added style map has the greatest precedence.
  See the section ["Writing style maps"](#writing-style-maps) for a description of the syntax.

* `DocumentConverter disableDefaultStyleMap()`: by default,
  any added style maps are combined with the default style map.
  Call this to stop using the default style map altogether.

* `DocumentConverter disableEmbeddedStyleMap()`: by default,
  if the document contains an embedded style map, then it is combined with the default style map.
  Call this to ignore any embedded style maps.

* `DocumentConverter preserveEmptyParagraphs()`: by default, empty paragraphs are ignored.
  Call this to preserve empty paragraphs in the output.

* `DocumentConverter idPrefix(String idPrefix)`:
  a string to prepend to any generated IDs,
  such as those used by bookmarks, footnotes and endnotes.
  Defaults to the empty string.

* `DocumentConverter imageConverter(ImageConverter.ImgElement imageConverter)`:
  by default, images are converted to `<img>` elements with the source included inline in the `src` attribute.
  Call this to change how images are converted.

#### `Result<T>`

Represents the result of a conversion. Methods:

* `T getValue()`: the generated text.

* `Set<String> getWarnings()`: any warnings generated during the conversion.

#### Image converters

An image converter can be created by implementing `ImageConverter.ImgElement`.
This creates an `<img>` element for each image in the original docx.
The interface has a single method, `Map<String, String> convert(Image image)`.
The `image` argument is the image element being converted,
and has the following methods:

* `InputStream getInputStream()`: open the image file.

* `String getContentType()`: the content type of the image, such as `image/png`.

* `Optional<String> getAltText()`: the alt text of the image, if any.

`convert()` should return a `Map` of attributes for the `<img>` element.
At a minimum, this should include the `src` attribute.
If any alt text is found for the image,
this will be automatically added to the element's attributes.

For instance, the following replicates the default image conversion:

```java
DocumentConverter converter = new DocumentConverter()
    .imageConverter(image -> {
        String base64 = streamToBase64(image::getInputStream);
        String src = "data:" + image.getContentType() + ";base64," + base64;
        Map<String, String> attributes = new HashMap<>();
        attributes.put("src", src);
        return attributes;
    });
```

where `streamToBase64` is a function that reads an input stream and encodes it as a Base64 string.

## Writing style maps

A style map is made up of a number of style mappings separated by new lines.
Blank lines and lines starting with `#` are ignored.

A style mapping has two parts:

* On the left, before the arrow, is the document element matcher.
* On the right, after the arrow, is the HTML path.

When converting each paragraph,
Mammoth finds the first style mapping where the document element matcher matches the current paragraph.
Mammoth then ensures the HTML path is satisfied.

### Freshness

When writing style mappings, it's helpful to understand Mammoth's notion of freshness.
When generating, Mammoth will only close an HTML element when necessary.
Otherwise, elements are reused.

For instance, suppose one of the specified style mappings is `p[style-name='Heading 1'] => h1`.
If Mammoth encounters a .docx paragraph with the style name `Heading 1`,
the .docx paragraph is converted to a `h1` element with the same text.
If the next .docx paragraph also has the style name `Heading 1`,
then the text of that paragraph will be appended to the *existing* `h1` element,
rather than creating a new `h1` element.

In most cases, you'll probably want to generate a new `h1` element instead.
You can specify this by using the `:fresh` modifier:

`p[style-name='Heading 1'] => h1:fresh`

The two consecutive `Heading 1` .docx paragraphs will then be converted to two separate `h1` elements.

Reusing elements is useful in generating more complicated HTML structures.
For instance, suppose your .docx contains asides.
Each aside might have a heading and some body text,
which should be contained within a single `div.aside` element.
In this case, style mappings similar to `p[style-name='Aside Heading'] => div.aside > h2:fresh` and
`p[style-name='Aside Text'] => div.aside > p:fresh` might be helpful.

### Document element matchers

#### Paragraphs, runs and tables

Match any paragraph:

```
p
```

Match any run:

```
r
```

Match any table:

```
table
```

To match a paragraph, run or table with a specific style,
you can reference the style by name.
This is the style name that is displayed in Microsoft Word or LibreOffice.
For instance, to match a paragraph with the style name `Heading 1`:

```
p[style-name='Heading 1']
```

You can also match a style name by prefix.
For instance, to match a paragraph where the style name starts with `Heading`:

```
p[style-name^='Heading']
```

Styles can also be referenced by style ID.
This is the ID used internally in the .docx file.
To match a paragraph or run with a specific style ID,
append a dot followed by the style ID.
For instance, to match a paragraph with the style ID `Heading1`:

```
p.Heading1
```

#### Bold

Match explicitly bold text:

```
b
```

Note that this matches text that has had bold explicitly applied to it.
It will not match any text that is bold because of its paragraph or run style.

#### Italic

Match explicitly italic text:

```
i
```

Note that this matches text that has had italic explicitly applied to it.
It will not match any text that is italic because of its paragraph or run style.

#### Underline

Match explicitly underlined text:

```
u
```

Note that this matches text that has had underline explicitly applied to it.
It will not match any text that is underlined because of its paragraph or run style.

#### Strikethough

Match explicitly struckthrough text:

```
strike
```

Note that this matches text that has had strikethrough explicitly applied to it.
It will not match any text that is struckthrough because of its paragraph or run style.

#### All caps

Match explicitly all caps text:

```
all-caps
```

Note that this matches text that has had all caps explicitly applied to it.
It will not match any text that is all caps because of its paragraph or run style.

#### Small caps

Match explicitly small caps text:

```
small-caps
```

Note that this matches text that has had small caps explicitly applied to it.
It will not match any text that is small caps because of its paragraph or run style.

#### Ignoring document elements

Use `!` to ignore a document element.
For instance, to ignore any paragraph with the style `Comment`:

```
p[style-name='Comment'] => !
```

### HTML paths

#### Single elements

The simplest HTML path is to specify a single element.
For instance, to specify an `h1` element:

```
h1
```

To give an element a CSS class,
append a dot followed by the name of the class:

```
h1.section-title
```

To require that an element is fresh, use `:fresh`:

```
h1:fresh
```

Modifiers must be used in the correct order:

```
h1.section-title:fresh
```

#### Separators

To specify a separator to place between the contents of paragraphs that are collapsed together,
use `:separator('SEPARATOR STRING')`.

For instance, suppose a document contains a block of code where each line of code is a paragraph with the style `Code Block`.
We can write a style mapping to map such paragraphs to `<pre>` elements:

```
p[style-name='Code Block'] => pre
```

Since `pre` isn't marked as `:fresh`,
consecutive `pre` elements will be collapsed together.
However, this results in the code all being on one line.
We can use `:separator` to insert a newline between each line of code:

```
p[style-name='Code Block'] => pre:separator('\n')
```

#### Nested elements

Use `>` to specify nested elements.
For instance, to specify `h2` within `div.aside`:

```
div.aside > h2
```

You can nest elements to any depth.

## Missing features

Compared to the JavaScript and Python implementations, the following features
are currently missing:

* CLI
* Writing embedded style maps
* Markdown support
* Document transforms

## Donations

If you'd like to say thanks, feel free to [make a donation through Ko-fi](https://ko-fi.com/S6S01MG20).

If you use Mammoth as part of your business,
please consider supporting the ongoing maintenance of Mammoth by [making a weekly donation through Liberapay](https://liberapay.com/mwilliamson/donate).

redpajama_set_name: RedPajamaGithub


text:
// Copyright 2015 The Project Buendia Authors
//
// Licensed under the Apache License, Version 2.0 (the "License"); you may not
// use this file except in compliance with the License.  You may obtain a copy
// of the License at: http://www.apache.org/licenses/LICENSE-2.0
//
// Unless required by applicable law or agreed to in writing, software distrib-
// uted under the License is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES
// OR CONDITIONS OF ANY KIND, either express or implied.  See the License for
// specific language governing permissions and limitations under the License.

package org.openmrs.projectbuendia.webservices.rest;

import org.codehaus.jackson.map.ObjectMapper;
import org.openmrs.Concept;
import org.openmrs.Field;
import org.openmrs.Form;
import org.openmrs.FormField;
import org.openmrs.api.ConceptService;
import org.openmrs.api.FormService;
import org.openmrs.api.context.Context;
import org.openmrs.module.webservices.rest.SimpleObject;
import org.openmrs.module.webservices.rest.web.RequestContext;
import org.openmrs.module.webservices.rest.web.annotation.Resource;
import org.openmrs.module.webservices.rest.web.representation.Representation;
import org.openmrs.module.webservices.rest.web.response.ResponseException;
import org.openmrs.util.FormUtil;
import org.projectbuendia.openmrs.webservices.rest.RestController;

import java.io.IOException;
import java.util.ArrayList;
import java.util.Collections;
import java.util.HashMap;
import java.util.List;
import java.util.Map;
import java.util.SortedMap;
import java.util.TreeSet;
import java.util.regex.Matcher;
import java.util.regex.Pattern;

/**
 * REST resource for charts. These are stored as OpenMRS forms, but that's
 * primarily to allow for ease of maintenance (OpenMRS provides an editing UI).
 * @see AbstractReadOnlyResource
 */
@Resource(name = RestController.REST_VERSION_1_AND_NAMESPACE + "/charts",
    supportedClass = Form.class, supportedOpenmrsVersions = "1.10.*,1.11.*")
public class ChartResource extends AbstractReadOnlyResource<Form> {
    private static final Pattern COMPRESSIBLE_UUID = Pattern.compile("^([0-9]+)A+$");
    private final FormService formService;
    private final ConceptService conceptService;

    public ChartResource() {
        super("chart", Representation.DEFAULT, Representation.FULL);
        formService = Context.getFormService();
        conceptService = Context.getConceptService();
    }

    /**
     * Retrieves a single form with the given UUID.
     * @param context the request context; specify the URL query parameter
     *                "?v=full" to get a list of the groups and concepts in the form.
     * @see AbstractReadOnlyResource#retrieve(String, RequestContext)
     */
    @Override public Form retrieveImpl(String uuid, RequestContext context, long snapshotTime)
        throws ResponseException {
        return formService.getFormByUuid(uuid);
    }

    /**
     * Populates the {@link SimpleObject} with 'version' (the version number of the form)
     * and, if details are requested with the query parameter "?v=full", adds the list of
     * chart sections in 'sections' containing the details of each tile or row in the chart.
     * @param context the request context; specify the URL query parameter
     *                "?v=full" to get a list of the groups and concepts in the form.
     */
    @Override
    protected void populateJsonProperties(Form form, RequestContext context, SimpleObject json,
                                          long snapshotTime) {
        json.put("version", form.getVersion());
        if (context.getRepresentation() != Representation.FULL) return;

        List<Map> sections = new ArrayList<>();
        SortedMap<Integer, TreeSet<FormField>> structure = FormUtil.getFormStructure(form);
        for (FormField sectionFormField : structure.get(0)) {
            Field sectionField = sectionFormField.getField();
            Map<String, Object> section = parseFieldDescription(sectionField);
            section.put("label", sectionField.getName());
            List<Map> items = new ArrayList<>();
            for (FormField itemFormField : structure.get(sectionFormField.getId())) {
                Field itemField = itemFormField.getField();
                Map<String, Object> item = parseFieldDescription(itemField);
                item.put("label", itemField.getName());
                item.put("concepts", getConceptUuids(item.get("concepts"), itemField));
                item.put("required", itemFormField.getRequired());
                item.remove("concept");
                items.add(item);
            }
            section.put("items", items);
            sections.add(section);
        }
        json.put("sections", sections);
    }

    /**
     * Returns a list of compressed concept UUIDs (see compressUuid), given the "concepts"
     * member of a field's description JSON.  If the "concepts" members is missing, returns
     * the field's concept.  The description is assumed to be correctly formatted, i.e. the
     * concepts argument should be a list of integer IDs of existing concepts.  Otherwise, an
     * uncaught exception will be thrown (as with any other case of internal database corruption).
     */
    private List<Object> getConceptUuids(Object concepts, Field field) {
        if (concepts == null) {
            return Collections.singletonList(compressUuid(field.getConcept().getUuid()));
        }
        // If the casts in this method fail, we want it to produce an uncaught exception and
        // HTTP error 500 (not error 4xx, which is for invalid user input).
        List conceptIds = (List) concepts;
        List<Object> result = new ArrayList<>();
        for (Object item : conceptIds) {
            int id = (Integer) item;
            Concept concept = conceptService.getConcept(id);
            if (concept == null) {
                throw new IllegalStateException("Concept " + id + " not found");
            }
            result.add(compressUuid(concept.getUuid()));
        }
        return result;
    }

    /**
     * Saves a bit of JSON space by using integers to represent UUIDs that are exactly 36
     * consist of an integer followed by a string of "A"s.  All other UUIDs are left as strings.
     */
    private static Object compressUuid(String uuid) {
        Matcher matcher = COMPRESSIBLE_UUID.matcher(uuid);
        if (uuid.length() == 36 && matcher.matches()) {
            return Integer.valueOf(matcher.group(1));
        }
        return uuid;
    }

    private static Map<String, Object> parseFieldDescription(Field field) {
        String description = field.getDescription().trim();
        if (description.startsWith("{\"")) {
            try {
                Map<String, Object> config =
                    new ObjectMapper().readValue(field.getDescription(), Map.class);
                for (String key : config.keySet()) {
                    if (config.get(key) == null || "".equals(config.get(key))) {
                        config.remove(key);
                    }
                }
                return config;
            } catch (IOException e) {
                throw new InvalidObjectDataException(
                    "Invalid JSON in description of field " + field.getId());
            }
        } else return new HashMap<String, Object>();
    }

    /**
     * Returns all charts (there is no support for searching or filtering).
     * @param context the request context; specify the URL query parameter
     *                "?v=full" to get a list of the groups and concepts in each form.
     * @see AbstractReadOnlyResource#search(RequestContext)
     */
    @Override protected Iterable<Form> searchImpl(RequestContext context, long snapshotTime) {
        return getCharts(formService);
    }

    public static List<Form> getCharts(FormService formService) {
        List<Form> charts = new ArrayList<>();
        String[] uuids = Context.getAdministrationService()
            .getGlobalProperty(GlobalProperties.CHART_UUIDS)
            .split(",");
        for (String uuid : uuids) {
            Form form = formService.getFormByUuid(uuid);
            if (form == null) {
                throw new ConfigurationException(GlobalProperties.CHART_UUIDS +
                    " property is incorrect; cannot find form " + uuid);
            }
            charts.add(form);
        }
        return charts;
    }
}


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text:
Elka de Levie (21 November 1905 – 29 December 1979) was an Amsterdam-born Dutch gymnast who won the gold medal as member of the Dutch gymnastics team at the 1928 Summer Olympics in Amsterdam. She was the only Jewish team member to survive the Holocaust; her teammates Anna Dresden-Polak, Jud Simons and Helena Nordheim and coach Gerrit Kleerekoper were gassed in Sobibor, while Estella Agsteribbe was gassed in Auschwitz. The entire team was elected to the International Jewish Sports Hall of Fame in 1997.

On 31 October 1929 she married Andries Abraham Boas, with whom she had two daughters, but the couple were divorced on 20 April 1943. She and both her daughters survived the Second World War by going into hiding. Elka de Levie died in anonymity in Amsterdam on 29 December 1979.

See also
List of select Jewish gymnasts

References

Further reading

External links
 Database Olympics profile
 Elka de Levie commemoration, Yad Vashem website

1905 births
1979 deaths
Dutch female artistic gymnasts
Dutch Jews
Jewish gymnasts
Jewish Dutch sportspeople
Gymnasts at the 1928 Summer Olympics
Olympic gymnasts of the Netherlands
Olympic gold medalists for the Netherlands
Gymnasts from Amsterdam
Dutch Holocaust survivors
Olympic medalists in gymnastics
International Jewish Sports Hall of Fame inductees
Medalists at the 1928 Summer Olympics