We all recognize the importance of incorporating organic and whole foods into our diet, but there is no need to spend all day in the kitchen. Instead, it is time to replace 'homemade' with 'hand touched'.
We don't all have the time to make a meal from scratch nor do we have the want. For example, rather than making your own paste when cooking a curry, there is nothing wrong with using a curry mix. If a delicious dinner can be achieved via this manner then what is the problem? Keeping that in mind, read on to discover a bit more about this trend and how our cooking approaches are changing.
Nowadays we certainly have a new wave of home gourmet cooks. One of the reasons why this is the case is because of the rise of the Internet. In the past, consumers were very brand loyal and would buy their fresh ingredients from the same store and brand. This is something that is actually changing.
At the moment, approximately 30 percent of the population are between 15 and 35 years old. These people are tech-savvy and socially engaged; they spend their days using social media and aren't afraid to look for something new and different. They are less brand loyal and more inquisitive. They want to know the story behind the brands and the products they are buying into.
As touched upon in the introduction, one of the main trends of the new gourmet at home cook is hand touched replacing handmade. It is all about finding a balance. The new cook wants to make delicious dishes from scratch but they also want to do so quickly. They want to achieve the high levels of quality and flavour but they don't want to spend hours measuring ingredients and such like.
This is why companies like Hello Fresh and Blue Apron are proving to be so popular. Consumers receive a meal kit with the recipe and all of the ingredients needed to create the dish. All food is fresh, pre-chopped and ready to use. This eliminates hassle and cuts time, however, it ensures that you reap all of the benefits of cooking with fresh food.
Aside from the points that have already been mentioned, the new wave of gourmet chefs places a great emphasis on healthy eating, preferring a healthy dinner over a processed one. They also aren't afraid to be experimental and use spices and herbs that previously would have been snubbed in the kitchen. When it comes to equipment, they are buying gadgets that would have once only be found in restaurants, such as espresso machines.
These are the trends of today. Have you made the switch from handmade to hand touched?


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Drei Türme steht für:

 Drei Türme (Rätikon), Bergkette in den Zentralalpen
 Drei Türme,  Felsformation im Lechquellengebirge,  Vorarlberg
 Drei Türme (Luxemburg), Teil der ehemaligen Festung Luxemburg

redpajama_set_name: RedPajamaWikipedia


We'll go through each of the nine main report types—their formatting requirements, the components of each one, and how they are used in the clinical setting. We'll review grammar points in every lesson, pointing out important elements that will make your reports perfect. You'll also gain important clinical knowledge of major disease processes that are essential to enhance your skill as a medical documentation specialist.
Along the way, we'll download a free transcriber that you'll use to listen to dictation, and we'll cover how to use it to produce the reports in your word processor. These hands-on exercises will give you the practice you'll need to determine if this field is for you. We'll also go through the options you'll have now and in the future by developing the skills of a medical transcriptionist.
In this first lesson, we'll look at the history of medical transcription as a career. You'll find out how the field has evolved into its modern form, and you'll explore the various skills and aptitudes that you'll need to succeed as a professional medical transcriptionist. You'll examine the type of work MTs produce, and we'll take a look at the MT's job today, where you might work, and what might be in store in the future for those working in this career field.
We'll start today by discussing the MT's tools of the trade. We'll review a few of the reference books and discuss the types of Web sites that MTs use for research. Then we'll take a look at the hardware and software that today's MTs use on the job. I'll talk you through downloading the free software we'll use in this course, and then we'll go through a quick tour on how to use it. By the end of this lesson, you'll be sitting at your computer, listening to a real medical dictation audio file and looking at the Express Scribe software on your screen. As you listen to the medical report, you'll practice starting, pausing, and rewinding the audio as you tap away on the keyboard.
There are nine report types that medical professionals use most often in both hospitals and clinics. So in this lesson we'll go over a variety of examples of real medical reports. We'll also do a quick review of medical correspondence. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, you might need a refresher. We'll finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then you'll practice transcribing a medical letter and a pathology report.
We'll spend this lesson going over how to listen most effectively, discussing the difference between hearing and active listening. We'll also touch on many of the issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. Then we'll discuss how you can use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Then we'll talk a bit about the radiology department and radiology reports, and we'll finish up by practicing transcribing one in today's assignment.
Today we're going to talk about some subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But I promise this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better MT. Then, in our Practice Corner, we'll talk a little more about SOAP notes and then turn our attention to infectious diseases and medications. You'll also have the chance to transcribe a SOAP note and a radiology report in the assignment that accompanies the lesson.
We'll continue our examination of writing in this lesson by talking about style from the MT's perspective. When you're transcribing, you must follow editorial directions in spelling, capitalization, and typographical display. And it's those directions that are the style MTs need to be concerned about. I think you'll be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercased? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? These are the issues we'll be covering in this lesson. Finally, in our Practice Corner, we'll focus on the H&P report, and you'll have the chance to practice transcribing one.
No matter what you transcribe, one thing is a given: Medical terminology will be a huge part of it. That's what we'll be focusing on today. One thing to remember is that dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like cystitome and cystotome. If you have a good understanding of medical terminology, you can pinpoint the correct word to make sure your transcription is accurate. Then, in our Practice Corner, I'll review the basic nature of heart disease and its treatment. We'll also take a close look at another common disease: diabetes.
A critical component of the MT's work is the way you put your reports together. So in this lesson, we'll talk about how to break up your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. We'll also take a closer look at ways you can make your work easier by using word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient MT! In the Practice Corner, we'll focus on surgical reports. Surgical terminology is important to know, and it's also fascinating to take an inside look at what goes on in the operating room. The assignment for this lesson will include a surgical report to help you put to work all the new knowledge you've gained.
Another essential step in transcription is editing and proofreading your work. And that's what we'll concentrate on today. I'll start off by sharing some editing do's and don'ts as well as what to look for when you're proofreading. In our Practice Corner, we'll be covering a disease process that has, in some way, touched virtually everyone: cancer. Once you have an overview of cancer, we'll work on the consultation report. Physicians often ask specialists to further evaluate their patients, especially cancer patients. So this is a common report that you're likely to transcribe regularly. The assignment for this lesson includes a consult report to transcribe, and you'll also get to practice proofreading.
So far we've focused on the mechanical elements of medical transcription. But there is still a lot you need to know about clinical issues. So this will be a completely clinical lesson. We'll talk about classification systems and their transcription foibles. And now that you have the bones of grammar and style down, we're going to talk about some real bones. We'll begin by discussing information on fractures and spine levels. Finally, in our Practice Corner, we'll discuss discharge and death summaries. They are very similar reports, but we'll take a look at some of their subtle differences.
This lesson will be similar to the last in that it covers lots of clinical issues. It won't all be clinical, however. There are a few miscellaneous things that I want to make sure I share with you. They don't really fit into neat categories, so I've put them all here. Once we finish with these miscellaneous items, we'll jump back into some clinical issues. We'll be talking specifically about infections. Then we'll turn our attention to smaller parts of the body—cells and blood. Then, in our Practice Corner, you'll see how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you'll ever come across. And, of course, you'll have the chance to transcribe an autopsy report in the assignment!
By now you have the tools and the knowledge you need to dip your toe into the waters of medical transcription. But we still have a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist? And do you need more training? Today we'll discuss all the different ways you can work—everything from being an independent contractor all the way up to consultant work. We'll talk about additional training as well. Then we'll take a peek at some of the events on the horizon, and you'll see why this is an exciting time to enter the transcription field. For our final Practice Corner, we'll look at the Health Story Project. It's an initiative to develop standards for integrating narrative reports (like the ones you've been transcribing) into the electronic medical record in a meaningful way—giving them the ability to be searched and to extrapolate data like we have never been able to do before.
It is recommended that students have prior knowledge of medical terminology and touch-typing before enrolling in this course.
Jennifer Della'Zanna graduated from Albright College in Reading, PA with a Bachelor of Arts degree. With 15 years' experience in the health care industry, she has worked as a medical transcriptionist, receptionist, medical assistant, practice administrator, biller, and coding specialist. She has written and edited courses and study guides on medical coding, transcription, and using technology in health care. She regularly writes feature articles about health issues for online and print publications. Jennifer is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity.


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Bringing farm life into the heart of the city — Gorgie City Farm Special
By Gemma Fox Aug 1, 2011 in Travel
Edinburgh - As a city, Edinburgh has many attractions both old and new and many that are designed specifically to draw in the tourists. However, there are a few that are more well known to locals and this article is about one of them.
While most tourists to Edinburgh could tell you about attractions like the Castle, the Dungeons and even the Zoo it's highly unlikely that many of them would be able to tell you much about Gorgie City Farm, if they had even heard of it in the first place.
Gorgie City Farm is nestled among tenements, schools, shops, sports stadiums and lies on a busy main road, Gorgie Road, which is one of the main arteries in and out of the city. It's also only a short bus ride from the centre of town.
Back in 1977 the land on which the farm now lies was derelict. There were a few plans tabled which would have seen houses built on the site but people in the area decided that they'd rather see the area developed as a green space and, thanks to the works of a local community group, the area was opened as Gorgie City Farm in 1982. Since then the farm has had tens of thousands of visitors each year.
The farm has a lovely tradition of calling the senior cow Bunty Anderson after one of the main people who helped to develop the farm.
The farm is a combined educational and working farm and produce from the farm, including eggs, lambs, vegetables and manure, are sold to help with the cost of running the farm. The farm is a registered charity and is run by a board.
Visitors to the farm gain entry for free and the farm relies on donations as well as the money made from sales of the above mentioned products.
For many Edinburgh children the city farm is the first opportunity to experience farm life and farm animals first hand. Currently visitors to the farm can see cows, sheep, pigs (and piglets), chickens, turkeys, goats and horses. Added to that is the farms Wildlife Garden where one of the attractions if the frog pond. It may take a while but the frogs are there to be spotted!
Gemma Fox
The farm also has a Pet Lodge which allows visitors to hold a variety of other animals such as rabbits, snakes, guinea pigs, chickens and tortoises.
The farm is also currently residence to Abbie a female Bengal Eagle Owl who can be seen peeking through the undergrowth in the picture below.
The education centre helps children and other visitors gain understanding of agriculture and animals and animal care in general. The farm itself allows many teenagers to gain work experience in the field of farming. Although there are paid staff at the farm it's also kept going by an army of dedicated volunteers who gain knowledge of farming life while also continuing to bring a taste of farming life to the centre of the city of Edinburgh.
For more information on the farm please visit the website.
More about gorgie city farm, Edinburgh, bunty anderson, Farming, Volunteers
gorgie city farm Edinburgh bunty anderson Farming Volunteers Castle Zoo bengal eagle owls Travel Environment

redpajama_set_name: RedPajamaCommonCrawl


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Ex charged over suitcase murder
news.com.au 02/13/2019 19:53:00
Javier Rojas admitted binding her hands and feet, taping up her mouth and dumped her body. But one thing just doesn't add up.
News Corp Australia NetworkFebruary 14, 20196:53am
Javier Enrique Da Silva Rojas has been charged with the murder of his ex girlfriend, whose body was stuffed in a suitcase and dumped by the side of the road.
Rojas, 24, confessed to police that he put Valerie Reyes in the suitcase, bound her hands and feet, put packing tape over her mouth and dumped her body but says he didn't kill her.
Rojas says that he hooked up again with Reyes, after the pair split up a year ago, and that she fell and hit her head while they were having sex.
It is not clear why Rojas felt like he had to get rid of the body. He is also yet to explain why he tried to use Reyes' ATM card to withdraw $US1000.
Reyes' body was found on February 5 after being reported missing on January 30. Police say she did not die in the location where her body was found.
The victim predicted her killing, telling her mother on the phone that she feared she'd be killed on January 28, a day before she disappeared.
"I'm worried someone is going to murder me," Reyes allegedly blurted out, according to her mother Norma Sanchez
"I asked her why do you feel this way? Was there someone at your house?" Reyes' mother said.
She asked about her daughter's ex-boyfriend but still Reyes told her mother 'no, it wasn't him'.
Police said in a statement that the ATM card use led them to Rojas.
"New Rochelle Police Detectives accompanied by Greenwich Police Detectives, arrested a suspect in New York who had fraudulently used the ATM card of homicide victim Valerie Reyes," they said. "The arrested individual is also believed to be involved in the death of Valerie.
"We are confident that the pursuit of justice for Valerie will be successful and we continue to work with the family to provide closure to this tragedy," the police statement said.
Originally published as Suitcase killer's incredible claim


A few minutes back, downloaded WordPress Android to try it out on my mobile. When android application are being reviewed one thing we must understand that these are very usefull and tiny application. And they are almost doing the same. The disk and the memory footprint used by these programs are one to tens of hundreds of their big brothers being used in PCs or notebooks. And they are just not too slow (although the oldest computing devices were too fast compare to computing speed of maximum human being …..So I still do not understand what is too slow as far as it is not games)…….
Real eager to see those smalls are conquring the PC and Laptops….
the SAP tools, and an SAP operating system or database migration check.
consulting service that is subject to charge.


Finland has most of the features that belong to a Scandinavian country; however, it does not necessarily label itself as one. Of course, one of the main commonalities with the Nordics is the frosty weather. Summers are a bit better; the temperature sometimes rises above +20 °C. Not only the weather but Finns themselves often seem as cold and quiet too. Perhaps it's because they are not the world's most sparkling conversationalists. They don't like to chit-chat, and they don't see the need to fill in those awkward silence gaps.
But we all know that stereotypes rarely convey the entire truth. This week's Featured Local is Riikka, she is the complete opposite of the above-mentioned stereotype, she's chatty and witty, and she's also our Showarounder based in Helsinki, the capital of Finland. Riikka is a design student, a foodie, a movie enthusiast and a lover of all things beautiful.
According to Riikka, "My ideal tour is laid back and full of art and culture. I will show you around the best art exhibitions and take you to the cutest cafes. I also love getting to know cities by walking so we could discover some of the most beautiful areas and buildings in town together."
What's our advice when travelling to Finland? Visit Helsinki, and don't let stereotypes fool you, better see it for yourself, how fantastic the place is.


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Dona M. Jayakody
Ear Science Institute Australia, Australia
University of Western Australia, Australia
Elaine Y.M. Wong
Front. Aging Neurosci., 26 April 2019
Sec. Neurocognitive Aging and Behavior
Volume 11 - 2019 | https://doi.org/10.3389/fnagi.2019.00097
Cingulate Cortex Atrophy Is Associated With Hearing Loss in Presbycusis With Cochlear Amplifier Dysfunction
Chama Belkhiria1,2, Rodrigo C. Vergara1,2, Simón San Martín1,2, Alexis Leiva1,2, Bruno Marcenaro1,2, Melissa Martinez3, Carolina Delgado1,3 and Paul H. Delano1,2,4*
1Department of Neuroscience, Faculty of Medicine, University of Chile, Santiago, Chile
2Biomedical Neuroscience Institute, Faculty of Medicine, University of Chile, Santiago, Chile
3Department of Neurology and Neurosurgery, Clinical Hospital of the University of Chile, Santiago, Chile
4Department of Otolaryngology, Clinical Hospital of the University of Chile, Santiago, Chile
Age-related hearing loss is associated with cognitive decline and has been proposed as a risk factor for dementia. However, the mechanisms that relate hearing loss to cognitive decline remain elusive. Here, we propose that the impairment of the cochlear amplifier mechanism is associated with structural brain changes and cognitive impairment. Ninety-six subjects aged over 65 years old (63 female and 33 male) were evaluated using brain magnetic resonance imaging, neuropsychological and audiological assessments, including distortion product otoacoustic emissions as a measure of the cochlear amplifier function. All the analyses were adjusted by age, gender and education. The group with cochlear amplifier dysfunction showed greater brain atrophy in the cingulate cortex and in the parahippocampus. In addition, the atrophy of the cingulate cortex was associated with cognitive impairment in episodic and working memories and in language and visuoconstructive abilities. We conclude that the neural abnormalities observed in presbycusis subjects with cochlear amplifier dysfunction extend beyond core auditory network and are associated with cognitive decline in multiple domains. These results suggest that a cochlear amplifier dysfunction in presbycusis is an important mechanism relating hearing impairments to brain atrophy in the extended network of effortful hearing.
Age-related hearing loss or presbycusis is characterized by bilateral progressive hearing loss and impaired speech understanding, especially in noisy environments (Gates and Mills, 2005). According to recent epidemiological data from the United States more than 50% of people aged over 70 years have presbycusis (Goman and Lin, 2016). In addition, due to population aging, it is expected that by the year 2025 there will be more than one billion people with hearing loss in the world (Sprinzl and Riechelmann, 2010). The increasing number of hearing loss patients is alarming, since epidemiological evidence has shown an association between presbycusis and cognitive decline in elderly people (Lin and Albert, 2014; Thomson et al., 2017). For instance, Lin et al. (2011) have shown that individuals with mild to moderate presbycusis have worse results in executive function and psychomotor processing, while other studies have shown that hearing loss is significantly related to global cognitive decline, which can lead to social isolation and depression (Harrison Bush et al., 2015; Panza et al., 2015). Furthermore, a recent prospective cohort has reported that presbycusis subjects with audiometric hearing thresholds worse than 40 dB are more likely to develop dementia (Deal et al., 2017). In line with this evidence, a Lancet consortium recently proposed a model in which hearing loss is the major potentially preventable risk factor for dementia (Livingston et al., 2017).
Although epidemiological and clinical studies confirm the relationship between hearing loss and cognitive decline, the mechanisms that relate them remain elusive (Lin and Albert, 2014; Wayne and Johnsrude, 2015). The pathological correlate of presbycusis can display different features, including cochlear hair cell loss, stria vascularis atrophy, and auditory-nerve neuron loss (Gates and Mills, 2005). Animal models of presbycusis have shown that in addition to the peripheral auditory damage, aged animals have less GABAergic neurons in the auditory cortex (Martin del Campo et al., 2012). In the same line, several human studies have found brain structural changes in patients with hearing loss, including gray matter volume reduction in the right temporal lobe (Lin et al., 2014; Peelle and Wingfield, 2016) and correlations between hearing impairment and smaller gray matter volume in the auditory cortex (Peelle et al., 2011; Eckert et al., 2012). However, whether the atrophy of specific brain regions and cognitive domains in presbycusis patients are associated with cochlear receptor cell loss is unknown (Shen et al., 2018).
There are two types of receptor cells in the mammalian cochlea: inner hair cells (IHC) and outer hair cells (OHC). While, IHCs are related to sensory transduction of acoustic vibrations, OHCs are responsible for the cochlear amplifier mechanism, which allows high sensitivity and sharp frequency selectivity to low-intensity sounds (Brownell et al., 1985; Robles and Ruggero, 2001; Liberman et al., 2002). In natural hearing, the cochlear amplifier is fundamental for frequency discrimination and speech perception, and can be assessed through otoacoustic emissions (Oghalai, 2004).
Here we hypothesized that a cochlear amplifier dysfunction in presbycusis – an OHC loss – is associated with cognitive decline and structural brain changes in the elderly population. We studied the possible associations between cochlear OHC function (measured by distortion product otoacoustic emissions [DPOAE]), cognitive performance, and brain structure (magnetic resonance imaging, MRI) in a Chilean cohort of elders without dementia (ANDES) and with different levels of hearing loss.
All procedures were approved by the Ethics Committee of the Clinical Hospital of the University of Chile, permission number: OAIC752/15. All subjects gave written informed consent in accordance with the Declaration of Helsinki.
For this cross-sectional prospective study, a total of 142 patients aged ≥ 65 years (screened between 2016 and 2018) from Recoleta's primary health public center located in the city of Santiago (Chile) were evaluated for recruitment. According to the inclusion and exclusion criteria of the Auditory and Dementia study (ANDES), 96 subjects were included for neuropsychological, audiological and brain imaging assessments. Inclusion criteria were the following: patients older than 65 years without dementia, which was evaluated by a mini-mental state examination (MMSE) score ≥ 24 and preserved functionality measured by the Pfeffer activities questionnaire (Quiroga et al., 2004). Exclusion criteria of recruitment in the study were the following: (i) stroke or other neurological disorders; (ii) dementia; (iii) major psychiatric disorders; (iv) other causes of hearing loss different from presbycusis (e.g., conductive hearing loss); (v) patients using hearing aids and (vi) other causes of significant disability.
Audiological Evaluations
All the audiological evaluations were carried out by an experienced audiologist in a double wall soundproof room located in the Otolaryngology Department of the Clinical Hospital of the University of Chile. Air conduction pure tone audiometric (PTA) hearing thresholds were evaluated at 0.125, 0.25, 0.5, 1, 2, 3, 4, 6 and 8 kHz for each subject in both ears using a clinical audiometer (AC40, Interacoustics®). In addition, in order to rule out conductive hearing loss, bone conduction thresholds were measured at 0.25, 0.5, 1, 2, 3 and 4 kHz. All audiometric data presented in the present work refer to air conduction thresholds. The PTA at 0.5, 1, 2 and 4 kHz were calculated for each subject in both ears. Subjects were classified according to their hearing level: normal hearing (≤20 dB), mild presbycusis (>20 and ≤35 dB), and moderate presbycusis (>35 dB) based on the PTA of the better hearing ear. Moderate presbycusis subjects were referred to the Chilean program for hearing aids for elders >65 years.
Distortion Product Otoacoustic Emissions
Otoacoustic emissions are sounds emitted by the OHCs of the inner ear that can be measured through sensitive microphones (Kemp, 1978). DPOAEs are a type of otoacoustic emission, commonly measured in clinical and basic research as a non-invasive tool for assessing the OHC function of the cochlear receptor (Abdala and Visser-Dumont, 2001). In this study, DPOAE (2f1–f2) were measured as a proxy of the cochlear amplifier function, using an ER10C microphone (Etymotic Research®), presenting eight pairs of primary tones (f1 and f2, at 65 and 55 dB SPL, f2/f1 ratio of 1.22) in each ear at eight different 2f1–f2 frequencies: 707, 891, 1122, 1414, 1781, 2244, 2828 and 3563 Hz. Figure 1A shows an example of the spectrogram of the microphone signal obtained from the external ear canal of the subjects, in which a 2f1–f2 DPAOE peak can be observed. To consider the presence of a detectable DPOAE, we used an amplitude criterion: the amplitude of a given DPOAE (dB SPL) should be at least 6 dB above noise floor. Using this criterion, we counted the number of detectable DPOAEs per ear, going from 0 to 8: "0" means that the subject had no detectable DPOAE in that ear, and consequently that ear was classified as having cochlear amplifier dysfunction (see below), while "8" means that the subject had detectable DPOAEs at all tested frequencies in that ear (normal cochlear amplifier function); and "16" means that the subject had detectable DPOAE in all tested frequencies in both ears. In contrast with a method that only measures the amplitude of DPOAE, the procedure of counting the number of detectable DPOAE per ear allowed us to evaluate the cochlear amplifier function in the whole sample (n = 96), without eliminating subjects with no detectable DPOAEs (and no measurable amplitude in dB SPL), which is common in elderly subjects.
Figure 1. DPOAE measurements. (A) Example of the spectrogram of the microphone signal used to obtain the 2f1–f2 DPOAEs in response to f1 and f2 stimuli. DPOAE amplitudes are about 40–50 dB smaller than f1 and f2 primary tones. (B) Mean DPOAE amplitudes in response to the eight frequencies for left (blue) and right (red) ears (data shown as mean ± SEM). Notice that low frequency DPOAEs are larger in amplitude than high frequency DPOAEs. (C) Frequency histogram of the number of detectable DPOAE per subject for left (blue) and right (red) ears. Note that 24 and 26 subjects had no detectable DPOAEs in right and left ears, respectively.
All subjects and their relatives were evaluated by a neurologist during a structured interview and graded according to their cognitive complaints using the clinical dementia rating scale (Morris, 1993). Cognitive performances were assessed by an experienced psychologist in cognitive tests adapted for the Chilean population (Quiroga et al., 2004), including the MMSE for global cognition (Folstein et al., 1975), the Frontal Assessment Battery (FAB) for measuring executive function (Dubois et al., 2000), the Trail Making Test A (TMT A) for processing speed (Army Individual Test Battery, 1944), the Boston Nominating Test for Language (Kaplan, 1978), the Rey–Osterrieth Complex Figure Test for Visuospatial Abilities (Rey, 1959), the Backward Digit Span for Verbal Working Memory, and the total recall of the Free and Cued Selective Reminding Test (FCSRT) to explore verbal episodic memory (Grober et al., 1988). Depression was self-rated by the participants using the Geriatric Depression Scale (GDS), which consists of 15 YES/NO answer questions. Higher scores indicate higher levels of depression, with scores over five indicating significant depressive symptoms (Yesavage et al., 1983). Cognitive training was not performed in this study.
Neuroimaging data were acquired by a MAGNETOM Skyra 3-Tesla whole-body MRI Scanner (Siemens Healthcare GmbH®, Erlangen, Germany) equipped with a head volume coil. T1-weighted magnetization-prepared rapid gradient echo (T1-MPRAGE) axial images were collected, and parameters were as follows: time repetition (TR) = 2300 ms, time echo (TE) = 232 ms, matrix = 256 × 256, flip angle = 8°, 26 slices, and voxel size = 0.94 × 0.94 × 0.9 mm3. T2-weighted turbo spin echo (TSE) (4500 TR ms, 92 TE ms) and fluid attenuated inversion recovery (FLAIR) (8000 TR ms, 94 TE ms, 2500 TI ms) were also collected to inspect structural abnormalities. A total of 440 images were obtained during an acquisition time of 30 min per subject.
Morphometric Analyses
To determine the structural brain changes of controls and presbycusis individuals, we measured the volume and thickness of bilateral cortical regions. FreeSurfer (version 6.0)1 was used with a single Linux workstation using Centos 6.0 as was suggested by Gronenschild et al. (2012) for T1-weighted images analysis of individual subjects. The FreeSurfer processing involved several stages, as follows: volume registration with the Talairach atlas, bias field correction, initial volumetric labeling, non-linear alignment to the Talairach space, and final volume labeling. We used the "recon-all" function to generate automatic segmentations of cortical and subcortical regions. This command performs regional segmentation and processes gross regional volume in a conformed space (256 × 256 × 256 matrix, with coronal reslicing to 1 mm3 voxels). The function "recon-all" creates gross brain volume extents for larger-scale regions (i.e., total number of voxels per region): total gray and white matter, subcortical gray matter, brain mask volume, and estimated total intracranial volume.
Additionally, we measured the cortical thickness in native space using FreeSurfer tools. We calculated the cortical thickness of each mesh of vertices by measuring the distance between the point on one surface and the closest conforming point on the opposite surface. Then we measured the average of the two values calculated from each side to the other (Fischl and Dale, 2000). Based on the brain regions that have been previously studied in presbycusis (Lin et al., 2014; Rigters et al., 2017) our regions of interest were the bilateral frontal superior, temporal inferior, middle and superior gyri, parahippocampus, hippocampus, and amygdala. We also included as regions of interest, cortical areas that have been implicated in the neural networks of degraded speech comprehension: bilateral anterior cingulate cortex (ACC), posterior cingulate cortex (PCC), and precentral and postcentral gyri (Peelle and Wingfield, 2016).
SPSS software version 20.0 was used to perform statistical analysis of demographic data, audiometric measurements, neuropsychological test results and structural MRI data. The ANCOVA method was used to compare cognitive performances and volume and thickness differences between the three tested groups including age, sex, and years of education as covariables. Pearson correlations were performed according to the distribution of data.
We applied general linear models (GLM) to contrast the difference of correlations between the studied groups using PTA as predictor for both volume and thickness. Age, education and sex were adjusted as covariates. The results were corrected for the multiple comparison using a significant alpha value of p = 0.01 (Hagler et al., 2006). Regions with significant differences in GLM models were selected based on the results of multiple corrections, and their corresponding brain regions were represented using the scientific notation p-values. The volume and thickness of selected regions were calculated based on the spatially normalized images of each individual in Talairach space (Fischl et al., 2002). In addition, we performed partial correlations including age, sex and education as confound regressors to associate cognitive tests with anterior and PCC volume and thickness.
Demographics Characteristics
The mean age of the recruited subjects (n = 96, 63 female) was 73.6 ± 5.3 years [mean ± standard deviation (SD)] with an average educational level of 9.5 ± 4.2 years of schooling (mean ± SD). The audiometric hearing thresholds were normal in 32 subjects, while 44 and 20 individuals were considered as mild and moderate presbycusis, respectively. None of the 96 subjects used hearing aids at the moment of recruitment. A summary of demographic data, including age, sex, education, hearing level, smoking, and cardiovascular risk factors is presented in Table 1.
Table 1. Demographic characteristics of the ANDES cohort.
Cochlear Amplifier Function
Figure 1B shows the mean amplitudes of the DPOAEs measured at eight different frequencies per ear, while Figure 1C displays a frequency histogram of the number of detectable DPOAE per ear, showing a bimodal distribution with a peak below two DPOAE per ear, and a broad distribution for more than two detectable DPOAE per ear. According to this bimodal distribution of the number of detectable DPOAE, we decided to split data into two groups: (i) better preserved cochlear amplifier function (≥5 DPOAE in both ears) and (ii) cochlear amplifier dysfunction (<5 DPOAE in both ears). Figure 2 shows that the number of detectable DPAOE significantly correlates with age and audiometric hearing thresholds, meaning that a lower number of DPOAE is associated with more aged subjects and worse hearing thresholds.
Figure 2. The number of detectable DPOAEs correlates with age and hearing thresholds (PTA). (A) A significant negative Spearman correlation was found between age and the number of detectable DPOAE in both ears (∗∗p < 0.05, r = –0.38). (B) A significant negative Spearman correlation was found between the audiometric thresholds of the better hearing ear (PTA) and the number of detectable DPOAE in both ears (∗∗p < 0.05, r = –0.73). Green circles and purple triangles represent female and male subjects, respectively.
Next, in addition to the classification based on the cochlear amplifier status, we used the degree of hearing loss (PTA) to divide subjects into three groups: (i) Controls: normal hearing (≤20 dB PTA, better hearing ear) with preserved cochlear amplifier function (≥5 detectable DPOAE) (n = 31); (ii) mild and moderate presbycusis (>20 dB PTA, better hearing ear) with preserved cochlear amplifier (PCF) (n = 33); and (iii) mild and moderate presbycusis (>20 dB PTA, better hearing ear) with cochlear amplifier dysfunction (<5 detectable DPOAE) (CD) (n = 31). One subject could not be classified within these criteria as he presented normal hearing with cochlear amplifier dysfunction and was excluded for further analyses.
Table 2 shows a summary of the audiological and cognitive performance of the three groups (controls, PCF and CD) controlled by age, gender and years of education. There was a significant difference in age between controls and the group of presbycusis with cochlear amplifier dysfunction, while non-significant differences in age and education were found between the two presbycusis groups (PCF and CD). At the cognitive level, the group with presbycusis and cochlear amplifier dysfunction had worse executive function than the other groups.
Table 2. Demographic, audiological and cognitive differences between controls and presbycusis groups with and without cochlear amplifier dysfunction.
Structural Brain Changes
Our next step was to evaluate whether structural brain changes were associated with cochlear amplifier dysfunction. Hence, we compared the MRI volumes and thickness of cortical and limbic brain regions in the three groups (controls, PCF and CD) using ANCOVA models adjusted by age, sex and education. Structural volumes were normalized by the total estimated intracranial volume. The ANCOVA models for brain volumes yielded significant differences between the three groups in the precentral (F(2,89) = 3.92, p = 0.02) and postcentral gyri (F(2,89) = 3.92, p = 0.02), parahippocampus (F(2,89) = 4.55, p = 0.01) and amygdala (F(2,89) = 3.31, p = 0.04). Tukey post hoc tests showed significant differences between the CD and controls in the volume of precentral and postcentral gyri and parahippocampus. The only significant difference in brain volume between PCF and CD groups was obtained from parahippocampus (Table 3).
Table 3. Brain volume and thickness differences between the controls and presbycusis groups with and without cochlear amplifier dysfunction.
Regarding cortical thickness, we found significant differences in the ANCOVA models for ACC (F(2,89) = 3.04, p = 0.04), PCC F(2,89) = 4.17, p = 0.01), precentral gyrus (F(2,89) = 4.00, p = 0.02), postcentral gyrus (F(2,89) = 6.43, p = 0.002) and parahippocampus (F(2,89) = 3.3, p = 0.04). Tukey post hoc tests showed that the thickness of precentral and postcentral gyri in the CD group were significantly reduced compared to that of the control group, while the thickness of ACC and PCC in the CD group were thinner than those of the PCF group (Table 3).
Next, in order to isolate the effect of hearing levels and cochlear amplifier dysfunction on brain structures, we ran GLM analyses. The GLM contrasted the difference of associations between PCF and CD groups using PTA as predictor for both volume and thickness. This method can effectively select voxels that correlate with PTA when contrasting PCF and CD groups. The whole brain analyses of volume and thickness related to cochlear amplifier dysfunction revealed significant correlations between PTA and different brain regions (corrected by age, education and sex, and using a level of significance = p < 0.01) shown in red and blue colors in Figure 3. These associations were significant for large clusters of voxels in bilateral ACC and PCC. Cochlear amplifier dysfunction was also associated with significant negative correlations between PTA and volume and between PTA and thickness in scattered regions of the right superior temporal, right postcentral and left precentral areas. We also found small clusters resulting from positive correlation between PTA and volume in the right superior and middle frontal areas in the CD group (Figure 3A). Figure 4 shows examples of the correlations between PTA and bilateral ACC thickness in CD and PCF groups, illustrating that PTA was negatively correlated with the thickness of bilateral ACC gyri only in the CD group.
Figure 3. GLM models for brain volume (A) and cortical thickness (B) correlated with PTA in presbycusis patients. The GLM contrasts the difference of correlations between PCF and CD groups using PTA as predictor for both volume and thickness. Age, education and sex were adjusted as covariates. The color blue shows regions in which individuals with cochlear dysfunction had a higher rate of gray matter decrease compared to those with normal cochlear (p < 0.01). The color red shows regions in which individuals with cochlear impairment had a higher rate of gray matter increase compared to those with normal cochlear (p < 0.01).
Figure 4. Significant negative correlations between PTA and ACC thickness in presbycusis patients with cochlear amplifier dysfunction. Pearson correlations between PTA and anterior cingulate thickness for PCF (blue) and CD (green) groups.
Cognitive Performance, Depression Scores and Cingulate Cortices Volume and Thickness
Pearson partial correlation analyses were performed between the bilateral volume and thickness of ACC and PCC and cognitive performance in PCF and CD groups. Age, sex and education were controlled as covariates (Table 4). Correlations between cognitive tests and structural measures of ACC and PCC were different between CD and PCF groups. In CD patients, there were significant correlations between episodic memory (total recall in the FCSRT), nomination, verbal working memory tests and volume of the left ACC. On the other hand, processing speed and verbal working memory correlated with the volume of the left PCC, while visuospatial abilities with the right PCC. These results indicate that, in the group with cochlear amplifier dysfunction, the volume of cingulate cortices and cognition performance decreased together. In addition, there was a negative correlation between depression scores and ACC volume in the CD group, indicating that higher depressive symptoms were associated with a decreased ACC volume.
Table 4. Pearson partial correlation corrected by age, sex, and education between cognitive tests and volume and thickness of anterior and posterior cingulate cortex for PCF and CD groups (∗p < 0.05).
Regarding cortical thickness, we found significant correlations between visuospatial capacities and right ACC, processing speed and left ACC, and nomination with bilateral ACC in the CD group. The visuospatial capacities test also correlated significantly with the thickness of the right PCC in the CD group. Taken together, these results indicate that the more severe the cognitive impairment, the thinner the cortex is in the anterior and posterior cingulate area.
In this combined approach, we found that structural brain changes in presbycusis subjects with cochlear amplifier dysfunction extend beyond central auditory pathways, including the cingulo-opercular network which is fundamental for effortful hearing. In addition, these changes were associated with impairments in verbal and non-verbal cognitive domains and depressive symptoms.
Cochlear Amplifier Dysfunction and Hearing Loss
A reduced number of detectable DPOAEs correlated with age, confirming that cochlear damage increases with aging (Abdala and Dhar, 2012; Abdala et al., 2018). In addition, the number of DPOAE and hearing levels were also correlated, which could be explained by the fact that cochlear aging is one of the main causes of presbycusis (Gates and Mills, 2005). However, it is important to highlight that both measures (DPOAE and PTA) are not identical and several differences can be described. DPOAE are objective measures that can be obtained with a microphone positioned in the external ear canal of anesthetized or unconscious subjects, while audiometric thresholds need the voluntary response of individuals. DPOAEs specifically reflect the function of the cochlear amplifier located in the OHCs of the cochlear receptor (Robles et al., 1991), while audiometric thresholds depend on the normal function of the complete auditory pathway.
In our work, according to the bimodal distribution of DPOAE presence, we divided data of presbycusis patients into two groups with different levels of cochlear amplifier function. As the cochlear amplifier is essential for auditory sensitivity, frequency and speech discrimination (Robles and Ruggero, 2001), we hypothesized that the group of patients with loss of OHCs would have more severe neural and cognitive consequences of hearing loss. Indeed, our results showed that the CD group had worse executive functions in comparison with the group with PCF, even after adjusting by age, education, and sex. This finding is in agreement with previous reports showing that executive functions are associated with hearing impairment (Lin et al., 2011), but we extended this association showing that executive functions are more impaired in the group with cochlear amplifier dysfunction.
Cochlear Amplifier Dysfunction and Brain Structure
At the brain structural level, we compared the volume and cortical thickness of regions of interest that were previously reported to be related to hearing loss, but we also included areas beyond the temporal lobe, that have been involved in effortful hearing (Peelle and Wingfield, 2016). Our results confirm that hearing impairment was associated to right superior temporal volume decrease (Lin et al., 2014; Rigters et al., 2017), but also to right superior temporal thickness decrease in the CD group. Notably, in the group of patients with CD, hearing loss produced larger effects in the network of effortful hearing, including the ACC, PCC, precentral and postcentral cortices, and the parahippocampus (Figure 3). While these findings are in agreement with a study reporting volume decrease in the right ACC in a group of middle-aged hearing loss patients (Husain et al., 2011), our results stress the importance of cochlear amplifier function in the neural structures related to the effortful hearing network in aged people.
Previous studies using functional MRI in presbycusis patients have demonstrated activation of non-auditory cortical regions related to the extended cortical network that supports spoken language processing (Peelle et al., 2011; Sharma and Glick, 2016). The cingulo-opercular cortex is one of the principal components of this network (Peelle and Wingfield, 2016). Increased activation of this area is related to better speech comprehension in normal hearing subjects (Peelle, 2018), and in mild hearing loss patients during passive listening (Campbell and Sharma, 2013).
Our work shows that the atrophy of the ACC is associated with cognitive and emotional deficits in presbycusis patients with cochlear amplifier dysfunction. The ACC is a key structure of cognitive and emotional variables necessary for decision making and social behavior that has also been implicated in pain, negative affect, and autonomic networks (Fornito et al., 2004; Shackman et al., 2011). Interestingly, we found that in the CD group, the reduction of the ACC volume was correlated not only with impairments in tests related to language processing (episodic and verbal working memories and nomination), but also with non-language functions such as visuospatial abilities and processing speed (Table 4). The decrease in performance in non-auditory cognitive domains could be explained by an increased listening effort in the group of CD patients, which needs the recruitment of non-auditory brain areas, decreasing resources for other cognitive functions (Peelle, 2018).
Another possible mechanism to explain the relation between episodic memory and semantic impairment with ACC atrophy in presbycusis could be a functional disconnection between the temporal lobe and the cingulate region (Warrington and Weiskrantz, 1982), as the functional connectivity between the cingulate and temporal areas has been correlated with memory performance in patients with mild cognitive impairment. Furthermore, the cingulate region and the parahippocampus gyrus are key components of the default mode network (Greicius et al., 2003; Raichle, 2015) which were significantly atrophied in the group of presbycusis with cochlear amplifier dysfunction. Taken together, our findings suggest that the relations between the ACC atrophy and episodic memory impairment could reflect an impairment of the Papez circuit in presbycusis patients with cochlear amplifier dysfunction (Tsivilis et al., 2008; Carlesimo et al., 2011).
At the emotional level, several functional neuroimaging studies have found hypoperfusion of the ACC cortex in subjects with major depression (Fitzgerald et al., 2008). Accordingly, we found that the volume of the left ACC was correlated with depressive symptoms in the group with cochlear amplifier dysfunction. However, it is important to highlight that our study only included subjects with mild to moderate depressive symptoms that could be interpreted as "negative affect or sadness" (Mayberg et al., 1999).
In our study the volume and thickness of the right PCC was also significantly correlated with visuospatial abilities in the CD group. This could be explained by role of the right PCC and the right hippocampus in the cortical network associated with spatial abilities, including spatial navigation and egocentric orientation (Hirono et al., 1998; Burles et al., 2018), suggesting that presbycusis could contribute to these spatial deficits.
In addition to the atrophy of the limbic areas in the CD group, we found changes in sensorimotor brain regions. The volume and thickness of the precentral and postcentral gyri were significantly reduced in the group with CD in comparison with the two other groups (Figure 3). These results could be explained by aging, as these regions are known to be affected in elderly people with gait disorders. Another possibility is the recruitment of precentral and postcentral gyri for speech perception in situations with degraded acoustic signal as part of the extended network of language processing (Peelle et al., 2010; Peelle and Wingfield, 2016).
Why Is Cochlear Amplifier Dysfunction Associated With Brain Atrophy?
One possible explanation is that the loss of OHC could be a general indicator of accelerated cell death in the nervous system of elderly people (Shen et al., 2018). In this sense, we can speculate that the absence of DPAOE in mild presbycusis patients could be an early risk factor for detecting accelerated neurodegeneration that could lead to cingulate cortex atrophy and executive dysfunction. This hypothesis could be addressed by performing experiments with selective loss of OHC in animal models.
Another speculative mechanism is that the constant activation of the effortful listening network could produce an accelerated neurodegeneration of cingulate neurons caused by glutamate excitotoxicity (Eckert et al., 2009; Adank, 2012; Vaden et al., 2015). This mechanism has been proposed in other neuropsychiatric diseases with ACC atrophy including fibromyalgia (Luerding et al., 2008; Cagnie et al., 2014) and psychotic depression (Bijanki et al., 2014; Zhang et al., 2017). Moreover, the constant activation of the cingulate cortices and other regions of the extended language network in presbycusis patients with cochlear amplifier dysfunction could act as a "secondary injury" that triggers neurodegeneration in a susceptible brain (Sperling et al., 2011).
In our study, we have a relatively reduced number of presbycusis patients with moderate or severe hearing loss. This is partially due to the inclusion criterion that requires subjects to have never used hearing aids before the moment of recruitment. This criterion was planned to eliminate possible neural compensatory plasticity associated to the use of hearing devices, but it hindered the recruitment of moderate to severe presbycusis patients (as most of them had used hearing aids previously). Consequently, the majority of the study's subjects have only mild to moderate presbycusis. Another limitation of the present work is that DPOAE loss, aging and brain changes could be associated with other peripheral and central auditory impairments that might affect cognition. These factors include IHC damage, auditory-nerve fiber loss and central auditory processing abnormalities, which could also be associated with DPOAE loss. Finally, the three groups are not perfectly matched by age and PTA. We control this limitation using these and other variables as covariates when needed. This control has its limitations, however, given our conditions, main conclusions should not be affected (see Supplementary Materials 1, 2). Therefore, our results are promising, but more research using DPOAEs as predictor for cognitive and neural decline is needed to evaluate the extent of this relation.
In non-demented patients with mild to moderate presbycusis, cochlear amplifier dysfunction was associated with brain atrophy and cognitive decline. We found structural changes in non-auditory brain areas related to the extended language processing network: the anterior and posterior cingulate cortices, sensorimotor areas and the parahippocampus. The dysfunction of this network is related to impairments in cognitive domains beyond auditory processing. Future longitudinal studies should consider measuring DPOAE, as a potentially early biomarker of cognitive decline and structural brain alterations.
CB analyzed the data and wrote the manuscript. RV and SSM analyzed the data. AL, BM, and MM performed the data acquisition. CD and PD performed experimental design and data analysis, and edited the manuscript.
This work was funded by Proyecto Anillo ACT1403, PIA, CONICYT, Chile, by Proyecto Fondecyt 1161155 to PD, CONICYT, Chile. BNI, Proyecto ICM P09-015F. AC3E CONICYT BASAL FB0008. Postdoctoral FONDECYT grant 3160403 to RV, CONICYT, Chile, and by Fundación Guillermo Puelma, Universidad de Chile.
We thank Dr. Luis Robles for reading a previous version of this manuscript.
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fnagi.2019.00097/full#supplementary-material
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Vaden, K. I., Kuchinsky, S. E., Ahlstrom, J. B., Dubno, J. R., Eckert, M. A., and Eckert, M. A. (2015). Cortical activity predicts which older adults recognize speech in noise and when. J. Neurosci. 35, 3929–3937. doi: 10.1523/JNEUROSCI.2908-14.2015
Warrington, E. K., and Weiskrantz, L. (1982). Amnesia: a disconnection syndrome? Neuropsychologia 20, 233–248. doi: 10.1016/0028-3932(82)90099-9
Wayne, R., and Johnsrude, I. (2015). A review of causal mechanisms underlying the link between age-related hearing loss and cognitive decline. Ageing Res. Rev. 23, 154–166. doi: 10.1016/j.arr.2015.06.002
Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., et al. (1983). Development and validation of a geriatric depression screening scale: a preliminary report. J. Psychiatr. Res. 17, 37–49. doi: 10.1016/0022-3956(82)90033-4
Zhang, J., Guo, Z., Liu, X., Jia, X., Li, J., Li, Y., et al. (2017). Abnormal functional connectivity of the posterior cingulate cortex is associated with depressive symptoms in patients with Alzheimer's disease. Neuropsychiatr. Dis. Treat. 13, 2589–2598. doi: 10.2147/ndt.s146077
Keywords: presbycusis, neurodegeneration, dementia, cognition, cochlear amplifier
Citation: Belkhiria C, Vergara RC, San Martín S, Leiva A, Marcenaro B, Martinez M, Delgado C and Delano PH (2019) Cingulate Cortex Atrophy Is Associated With Hearing Loss in Presbycusis With Cochlear Amplifier Dysfunction. Front. Aging Neurosci. 11:97. doi: 10.3389/fnagi.2019.00097
Received: 23 October 2018; Accepted: 10 April 2019;
Published: 26 April 2019.
Dona M. P. Jayakody, Ear Science Institute Australia, Australia
Donald Robertson, The University of Western Australia, Australia
Elaine Y. M. Wong, Ear Science Institute Australia, Australia
Copyright © 2019 Belkhiria, Vergara, San Martín, Leiva, Marcenaro, Martinez, Delgado and Delano. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Paul H. Delano, pdelano@med.uchile.cl; phdelano@gmail.com
Association between Peripheral and Central Hearing Loss and Cognitive Impairment in Older Adults with Neurodegenerative Diseases


text:
Remígio é um município brasileiro do estado da Paraíba. Está localizado na Região Geográfica Imediata de Campina Grande. De acordo com o IBGE (Instituto Brasileiro de Geografia e Estatística), no ano de 2021 sua população era estimada em 19.973 habitantes. Área territorial de 178 km².

Geografia
O município está incluído na área geográfica de abrangência do semiárido brasileiro, definida pelo Ministério da Integração Nacional em 2005.  Esta delimitação tem como critérios o índice pluviométrico, o índice de aridez e o risco de seca.

Bairros
 Centro
 Brito Lira
 Bela Vista
 São Judas Tadeu (conhecido por Matadouro)
 Santo Antônio (conhecido por Baixa Verde)
 Freitas
 Monte Santo (conhecido por Gibão)
 Padre Cícero
 Lagoa do Mato

História
Os primeiros habitantes do atual município foram os índios Potiguares, que na região brejeira da Paraíba eram distribuídos em seis tabas, das quais, as de Jandaíra, Queimadas e Caxexa, localizavam-se em terras do atual município.

Não se tem dados precisos a respeito de quando começou o desbravamento da região, pressupõe-se que tenha sido no início do ano de 1700. Só 78 anos depois é que foi encontrado o primeiro registro, dando conta da presença de colonizadores naquele local, quando o Alferes Luiz Barbosa da Silva Freire, entrou em choque com o Governador da Província do Rio Grande do Norte e em luta armada, consegui fugir da sua terra, trazendo consigo dois escravos negros. Na fuga desenfreada, foi encontrar o português João Morais Valcacér, tendo com ele permutado sua propriedade (Barro Branco) no Rio Grande do Norte, pela de Chã de Jardim, em Areia, estendendo-se pouco tempo depois, até o lugar denominado Lagoas, hoje a cidade de Remígio.

Após estabelecer-se no local, trouxe a família, inclusive filhos e serviçais, iniciando com eles o desbravamento da propriedade, tendo conseguida a amizade dos índios.

Um dos genros do fazendeiro, chamado Remígio dos Reis, construiu sua morada próximo a uma das cinco lagoas existentes na região. A partir daí novas casas foram construídas e surgiram novos sítios, por este motivo o denominaram Lagoa do Remígio, tempos depois simplificado para Remigio. A principal atividade do lugarejo era a agricultura, sobressaindo-se culturas de café e cana de açúcar apesar de técnica rudimentar aplicada.

Formação Administrativa
Em divisão administrativa referente ao ano de 1911, figura no município de Areia o distrito de Lagoa do Remígio.

Assim permanecendo em divisões territoriais datadas de 31-12-1936 e 31-12-1937.

Pelo decreto-lei nº 1164, de 15-11-1938, o distrito de Lagoa do Remígio passou a denominar-se simplesmente Remígio.

Foi elevado à categoria de município com a denominação de Remígio, pela lei estadual nº 1667, de 14-03-1957, desmembrado de Areia. Em divisão territorial datada de 1-07-1960, o município é constituído do distrito sede.

Pela lei estadual nº 2778, de 18-01-1962, é criado o distrito de Algodão e anexado ao município de Remígio.

Em divisão territorial datada de 31-12-1963, o município é constituído de 2 áreas urbanas: Remígio e Algodão.

Pela lei nº 5.928, de 29-04-1994, desmembra do município de Remígio o distrito Algodão. Elevado à categoria de município com a denominação de Algodão de Jandaíra.

Lagoa do Remígio para simplesmente Remígio alterado, pelo decreto-lei estadual nº 1.164, de 15-11-1938. Gentílico: remigioense ou remigense Histórico Fonte IBGE.

Emancipação Política
A República veio encontrar Remígio desenvolvida social e economicamente, motivo pelo qual foi criado o Distrito de Paz em 1890, perdendo essa situação dois anos depois, isto é, em 1892, para reavê-la em 1910 e passando a vila, graças ao Decreto-lei nº. 1.164, de 15 de novembro de 1938, com a denominação simplificada para "Remígio". Remígio como todos os núcleos da região, passou pelas áureas fases do café e da cana-de-açúcar, acompanhado também, a decadência desses produtos. A emancipação Político-administrativa deu-se pela luta encetada pelo Dr. Simeão Cananéa, Estanislau Eloy e seus filhos, Severino Bronzeado e seus filhos Luiz e Epitácio Bronzeado, o primeiro Deputado Estadual já em duas legislaturas e o último, vendo-se coroado de êxito os seus esforços, teve a glória de ser nomeado seu primeiro prefeito. O município foi criado pela Lei estadual nº. 1.667 de 14 de março de 1957, sendo instalado a 31 de março do mesmo ano.

Ligações externas

Página da câmara

Fundações na Paraíba em 1957


Founded in 1997, Shenzhen Grandsun Electronic Co., Ltd. ("Grandsun Electronic") is a national high-tech enterprise winning the title of National Model Worker. As a developer and manufacturer of state-of-the-art hearable devices and a provider of complete solutions, Grandsun Electronic has established a sound system of research and development, design, manufacture, sale and integrated service, striving to offer professionalized and high-quality hearable devices and solutions.Grandsun Electronic has successively undertook the responsibility for overcoming the difficulties in several scientific research projects such as National Mobile Internet and 4G Special Project, Key New Product Program of Guangdong Province and Major Industrial Project of Shenzhen Municipality while its products are widely recognized for their several winnings of Red Dot, IF, CES and other international design awards.
Relying on its establishment of enterprise-university-research institute cooperation and alliance, Grandsun Electronic has founded a smart noise reduction technology research center with Peking University Shenzhen Graduate School, the Academician Yang Shuzi Smart Noise Reduction Studio and a smart noise reduction technology research center with Wuhan Institute of Technology, and a joint laboratory with School of Electronic Engineering, Xidian University, and possesses three R&D centers residing in Shenzhen, Nanjing and Hong Kong industrial park respectively.
In the course of exploring new technologies with respect to hearability, touch, health and mobile internet, Grandsun Electronic is committed to building a pleasant working environment with ample oxygen for every employee. Aiming to be a pioneer of "green development, recycling development and low-carbon development", Grandsun Electronic was successively awarded honorable titles such as Green Enterprise of Shenzhen Municipality, Advanced Enterprise of Waste Reduction in Shenzhen, Cleaner Production Enterprise of Shenzhen Municipality and Cleaner Production Enterprise of Guangdong Province. It strives to become "the prettiest company" offering every employee a pleasant environment for living and working with twitter of birds, fragrance of flowers, shade of trees and delicacy of food and drinks.
While pursuing technical innovations, high-quality products and the aim to be "the prettiest company", Grandsun Electronic helps every employee with career planning, delivers professional training, trains more outstanding talents and creates better value for the society.
冠旭电子 版权所有 @ 2019 Shenzhen Grandsun Electronic Co., Ltd. All Rights Reserved.


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text:
Clinical Jobs
Practice made perfect
View All Jobs at TeamHealth
Emergency Medicine Physician Assistant or Nurse Practitioner in Arlington, WA at TeamHealth
Become a part of TeamHealth's rich history by joining our team as a full-time physician assistant or nurse practitioner in the emergency department (ED) at Cascade Valley Hospital in Arlington, Washington. This is an excellent Full Time opportunity for an advanced practice clinician who has at least one year emergency medicine experience, post masters training to work between Cascade Valley and Island Hospital.
TeamHealth offers excellent support and resources to maintain a great work-life balance that gives you quality time with family and time to enjoy the community and the outdoors.
You'll be able to learn and grow alongside the best in emergency medicine, with mentors, education and avenues for professional development that feed into your career path at TeamHealth.
For more than 40 years, TeamHealth's history and national footprint in emergency medicine allows us to achieve the highest standards in care, informed by decades of evidence-based data. To that end, we've created robust risk management programs to help our clinicians feel confident in their work.
We harness a nationwide collection of tools, clinical resources and collective knowledge for our emergency medicine clinicians who provide the best for their patients. TeamHealth is proud to be one of the largest integrated healthcare providers in the country.
Excellent comprehensive benefits package
Access to professional development tools, educational resources and free CME through TeamHealth Institute
Association with a leading physician practice in the U.S.
Stability of a respected industry leader
Access to TeamHealth's clinician wellness program
Paid professional liability insurance with tail coverage
Practice with confidence as a member of the national Patient Safety Organization
Cascade Valley Hospital
Cascade Valley Hospital opened in 1901 to serve the greater Arlington community. The hospital underwent a significant renovation and expansion in 2010 and is now licensed for 48 beds. Patients are served by highly trained clinical nursing teams and board-certified hospitalists. Cascade Valley Hospital provides a multidisciplinary approach, with clinical specialists and support services available to provide compassionate, comprehensive care to every patient.
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text:
Spectrum of Histological Changes in Endometrial Biopsies with Abnormal Uterine Bleeding
Pordil Khan*, Farhan Abbas Baloch** and Ahmareen Khalid***
* Department of Pathology, Bacha Khan Medical College, Mardan, ** Department of Pathology, Pak International Medical
College, Peshawar, *** Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad.
Objective: To identify and characterize the diagnostic features of endometrial biopsies in cases presenting with abnormal uterine bleeding and to determine the types and frequencies of endometrial
pathologies in these cases.
Materials and Methods: The study was conducted at Department of Pathology, Pakistan Institute of Medical Sciences (PIMS), Islamabad. The duration of study was 6 months. The study included 100 cases of endometrial biopsies. Relevant clinical history was taken from the patient and the results of other investigations were also noted. The specimens were grossed and then processed. Cutting of sections was done at 3 to 5 microns, and stained with H&E. Slides were evaluated for positive histopathological findings.
Results: Most of the patients were in the age of 20 to 50 years with mean age of 37 years.
The various conditions responsible for abnormal uterine bleeding in this study were 34 cases of estrogen dominance, 10 cases of abnormal secretory phase, 6 cases of anovulatory endometrium, 6 cases of pill-effect endometrium, 3 cases of simple cystic hyperplasia, 3 cases of chronic endometritis, 2 cases of luteal phase defect and 1 case of atrophic endometrium. All these patients were in the age group 20 to 60 years and most of the samples were in the age group 30 to 45 years. Polymenorrhagea was the most common complaint. The results of this study are compared with national and international studies.
Conclusion: Hormonal imbalance is a very broad term and may lead to misinterpretation. It will be a challenge for the pathologists to do serum hormone levels for each and every patient and to correlate it
with histopathological findings. Complete clinical history is very important in this regard especially LMP and hormonal therapy has a
crucial role in the diagnosis of endometrial biopsies.
Keywords: Endometrium, estrogen dominance, abnormal secretory phase endometrium.


text:
Q: UIImagePickerController crash when trying to select panoramic image from phone library I am trying to select an image from device library using the UIImagePickerController all things works well unless i pick a very huge image ( a panoramic image) the app crash without giving any trace. I think it is a memory issue ( i noticed that the memory usage is increasing to 600m). So my question is can i specify an image size as a filter ? or should i create my custom image picker ? also i tested the same image using facebook and twitter image picker : twitter fail ...
my code launch the image picker is :
var picker = UIImagePickerController()
picker.delegate = self
picker.sourceType = .PhotoLibrary
presentViewController(self.picker, animated: true, completion: nil)

and capturing the selected image :
extension MYViewController : UIImagePickerControllerDelegate,UINavigationControllerDelegate{
    func imagePickerController(
    picker: UIImagePickerController,
    didFinishPickingMediaWithInfo info: [String : AnyObject])
    {
        print("user did select an image")
        let chosenImage = info[UIImagePickerControllerOriginalImage] as! UIImage

        dismissViewControllerAnimated(true, completion: nil)

    }
    func imagePickerControllerDidCancel(picker: UIImagePickerController) {
        //do code when cancel
        print("cancel ...")
        userDidCancelImageChoosing = true
        dismissViewControllerAnimated(true, completion: nil)
    }
}

edit: I checked the question of video duration but is not what I need we don't have the same problem, Here I talk about selecting image from the image picker you can try in the twitter app and attach a panoramic HQ image with huge size. The question suggested talk about limiting record video duration.

A: The App crashes due to large size of Image.you can resize the image using the following function.This function will return an image. If you want data then uncomment the two lines and return Data instead of image.
func compressImage(image:UIImage) -> UIImage {
    // Reducing file size to a 10th

    var actualHeight : CGFloat = image.size.height
    var actualWidth : CGFloat = image.size.width
    let maxHeight : CGFloat = 1136.0
    let maxWidth : CGFloat = 640.0
    var imgRatio : CGFloat = actualWidth/actualHeight
    let maxRatio : CGFloat = maxWidth/maxHeight

    if (actualHeight > maxHeight || actualWidth > maxWidth){
        if(imgRatio < maxRatio){
            //adjust width according to maxHeight
            imgRatio = maxHeight / actualHeight;
            actualWidth = imgRatio * actualWidth;
            actualHeight = maxHeight;
        }
        else if(imgRatio > maxRatio){
            //adjust height according to maxWidth
            imgRatio = maxWidth / actualWidth;
            actualHeight = imgRatio * actualHeight;
            actualWidth = maxWidth;
        }
        else{
            actualHeight = maxHeight;
            actualWidth = maxWidth;
            compressionQuality = 1;
        }
    }

    let rect = CGRect.init(x: 0.0, y: 0.0, width: actualWidth, height: actualHeight)

    UIGraphicsBeginImageContext(rect.size);

    image.draw(in: rect)
    let img = UIGraphicsGetImageFromCurrentImageContext();

    //        let imageData = UIImageJPEGRepresentation(img ?? UIImage.init(named: "imgPlaceHolder")!, compressionQuality);
    //
    //        UIGraphicsEndImageContext();
    //
    return img ?? image
}

Code to use this function
        picker.dismiss(animated: false, completion: {
            let img = self.compressImage(image: chosenImage)
            let cropViewController = TOCropViewController(image: img)
            cropViewController.delegate = self
            self.present(cropViewController, animated: false, completion: nil)

        })

redpajama_set_name: RedPajamaStackExchange


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The In-Ear Metronome is a unique style of metronome that you use by wearing it directly in your ear. Since the speaker unit fits directly in your ear, it's useful not only for personal practice with any instrument, but also when you want to hear an accurate rhythm without being drowned out by the sounds of your surroundings, such as if you are practicing while surrounded by high-volume instruments.
The tempo setting range is a generous 30--252 bpm, and a wide variety of beats and rhythms are provided. In spite of its ultra-small sized body, the In-Ear Metronome provides approximately 200 hours of continuous operation using a coin-type lithium battery. The In-Ear Metronome also includes a well-cushioned ear pad and a carrying case that neatly stores the In-Ear Metronome.


text:
Young and hungry roster will lead Lady Cru
Home » Sports » Young and hungry roster will lead Lady Cru
By Spencer Turner
When the team takes to the court Nov. 18 for its opening contest of the 2011-12 campaign, it will boast a roster rich in talent and potential but short in collegiate experience. A total of 11 freshmen join a squad that witnessed five of its members graduate last May.
Amid this new infusion of youth, however, the Lady Cru remain confident as the new season approaches.
"We believe we have a shot at the conference championship," said seven-year Head Coach Kim Kirkpatrick-Thornton. "We realize they're lofty, but we work towards the small goals first and build upward. The greatest goal is to learn to play to our potential all the time, no matter who we face."
Kirkpatrick-Thornton also stressed the team's desire to earn a berth in the Division III championship tournament in March.
Senior guard Miranda Shorter (4) shoots the ball during afternoon practice while teammates junior guard Cortney Poncik (5) and senior guard Lauren Reece (15) watch. The team has its first home game Nov. 26 against Centenary College at 1 p.m. Photo by Brooke Morgan.
Junior nursing major Brandy Dittert is one of seven starters returning from the previous year's squad. Sidelined by an injured anterior crucial ligament in the beginning weeks of last season, she is eager for the Lady Cru to put their first-round exit from the American Southwest Conference tournament behind them.
"For the talent we had, it was not the finish we had in mind," she said. "It wasn't easy to sit through."
Dittert expressed the same eagerness to become a team leader.
"I'm an upperclassman, and now it's my turn to fill the leadership role," she said. "It's nerve racking, but I want to be in that position."
Senior interdisciplinary studies major Miranda Shorter, a four-year veteran of the program, voiced similar excitement in providing guidance to her younger teammates throughout the upcoming season.
"I like being in that role," she said. "I've had good role models before me on the team to look up to."
Both returning starters understand from firsthand experience the steep learning curve younger members of the team must negotiate.
"You can't expect freshmen to know what it's like to play college teams right away," Shorter said. "They'll get it, though. We've all been there, and we know what it's like. The biggest key is working together as a team and getting them into our style (of basketball)."
Despite the lineup's shortage of collective playing time, Dittert and Shorter emphasized the competitiveness and versatility that define the group.
"There's such a variety of players; everyone can contribute in so many ways," Dittert said. "Our team has people with the biggest heart for the game."
Shorter said, "The (freshmen) will be good. All the returners have such confidence in them."
Kirkpatrick-Thornton praised the diligence, hustle and coachable demeanor exhibited by each player on and off the court.
"This may be one of the most enjoyable teams I've coached here," she said. "Their work ethic and attitude are some of their greatest strengths."
The Lady Cru expect to encounter stiff competition throughout the season.
Matchups with conference mainstays Howard Payne, Hardin-Simmons, and McMurry loom large on the schedule, while an improved program at Concordia looks to further crowd the road to an ASC title.
"The competition in the conference has gotten stronger every year," Kirkpatrick-Thornton said.
Dittert insisted this youthful edition of the Lady Cru is ready to accept the challenge.
"We're young, but we're a good team," she said. "We play well together. We have smart girls and we have the talent to compete."
To see the Women's Basketball schedule, click here.


Govs vs. Feds: Who Will Play The 'Power Card' In The Medicaid Struggle?
Medicaid is the rope in the current tug of war between the states and the federal government over health reform. So far, the feds think they are winning. But don't discount the strength and endurance of the states — and especially the governors.
States are facing severe budget pressures. The 2009 stimulus package provided short-term cash to the states to shore up Medicaid — the jointly funded federal-state health program for lower-income people. But in exchange, states had to agree to maintain their 2010 Medicaid eligibility levels or risk losing all federal matching funds.
In January, 33 governors and governors-elect wrote to President Barack Obama and congressional leaders requesting "flexibility and relief" from the "excessive constraints placed on us by healthcare-related federal mandates." States say they need to trim their Medicaid rolls now because they already are swimming in red ink and this circumstance will only get worse — partly because stimulus funding that initially helped many of them pay for the added enrollment ends in June. And, while Health and Human Services Secretary Kathleen Sebelius has responded by sending her agency's Medicaid experts to the states to help them explore options to trim Medicaid spending, she is still urging states to do everything they can to keep Medicaid enrollment at current levels before the health law's changes take effect in 2014.
These pleas for flexibility are bipartisan. For example, Democratic Gov. Jerry Brown of California is asking for permission to cut $1.7 billion from his state's Medicaid program by limiting most recipients to no more than 10 physician visits a year. Arizona's Republican Gov. Jan Brewer proposed tightening eligibility so the state could cut 280,000 people from its Medicaid rolls. Sebelius told her that Arizona didn't need to ask permission but could reduce its rolls by allowing an existing waiver to expire in September. But few other states have similar options.
Specifically, the new health overhaul law will require states to expand coverage by 2014 to all citizens under 133 percent of poverty — about $30,000 a year for a family of four. Recent estimates show that this will mean adding an additional 20 million people to the rolls by 2019. Under the new law, the program will grow to 84 million enrollees and will cost nearly $900 billion by 2019. This increasing enrollment will be accompanied by growing cost burdens on the states.
Still, some see these expansions as steps that could transform the program into a means for working people and families to have access to health coverage.
This scenario is already happening in some areas.
And, because Medicaid is an important safety net for many people who have no other options for health coverage, adding millions more recipients to the program without increasing the system's capacity will make it even more difficult for those currently on Medicaid to get the care they need.
Medicaid is arguably the worst health care program in the country. Recipients are promised a long list of benefits, but doctors who participate in the program are paid so little, and the paperwork is so onerous, that many can afford to see only a few Medicaid patients.
As a result, patients flood to hospital emergency rooms where — if they wait long enough — they eventually will be seen. Many have only routine health complaints that easily could have been handled in a doctor's office. A study by the National Center for Health Statistics found that Medicaid recipients were more likely to have multiple emergency room visits in a year than those with private insurance and the uninsured. Other studies have shown that Medicaid recipients are less likely to receive adequate care, and they are more likely to have worse outcomes than those with private insurance. They have also been shown to experience higher rates of hospital mortality than even the uninsured.
The program also is rife with fraud. New York State, where almost one in four residents is on Medicaid or its daughter program, the Children's Health Insurance Program, has tried to tackle wasteful spending. A 2005 investigation found that as much as 10 percent of the state's spending on Medicaid was lost to fraud and abuse.
You would have thought that reforming this program would have been Job One with the Congress and President Obama when they drew up their health reform plans. But Medicaid is as bureaucratic and rule-driven as ever. And this is the program that the president relies on to expand coverage to more than half of the newly insured.
Washington clearly is intent on expanding the program to enroll millions more people in this government-run health program while the states plead for more flexibility and relief from Washington.
The governors hold the power cards for health reform over the next two years, and they will continue to demand more flexibility to run the programs themselves. In this tug of war, I'm betting on the governors.
Published on Kaiser Health News, Feb. 28, 2011.