text:
DIANE SEVERIN NGUYEN
The perfect cracker would have:
black sesame, black pepper, pink volcano salt, minced garlic, chili powder, matcha powder, green onion, rosemary, basil, nutritional yeast, lemongrass, cinnamon, turmeric, charcoal, ginger, cardamom, and nori flakes …all embedded onto a rice flour crust and pounded into thin rectilinear planes, abandoned to scorch in the hot sunlight, internally bubbling up tiny pockets of warm air as evenly dispersed as a beehive.
Biting down should feel like crushing into an exoskeleton with no guts. Bumpy surfaces are relatable because they confuse inside and outside. An inclination towards dry foods because I am a hollow shell.
Shaking crumbs from my pillowcase, my mother would threaten me in her watered-down Buddhist way that I would surely become a cow or an ant in my next life. She never understood that this only invigorated my empathy with animals, envisioning their souls, to the point where I would often pretend to be an animal, as most children do, on my hands and knees, observing human life from a more knowing future (confusing the punishment of reincarnation as eternal suffering with Christian notions of transfiguration via the embodiment of christ).
Plasticity describes the deformation of a solid material undergoing irreversible changes of shape in reaction to applied forces. It should be clearly differentiated from elasticity which is the ability for a material to resist a distorting force by returning to its original form once that influence has been removed. In engineering terms, the transition from the elastic material to the plastic material is quantified as yield, which is to ask, how many times must it hurt before a new body emerges, but also raises the question of if a house quivers at the slightest breeze, is it still a house? Regardless, we all need a place to live. Regardless, the wind brings angular ships from cold, northern hemispheres towards humid landscapes with long coastlines.
Colonizers, who are notorious for their bad digestions, brought over gluten to Vietnam primarily in two innocuous forms: firstly, the thin lines of wheat noodles from northern China, and secondly, the rigid and narrow baguette from France. In both cases, the Vietnamese re-fleshed out these shapes with rice flour, resulting in lighter, crispier mouthfeels and gentler absorption into the gut. The oral history I vaguely remember is that rice originally appeared as a large ball falling from the sky into each and every home, on a daily basis, as an answer to mass prayers. Somewhere along the way, a woman eternally damaged this blessing by shattering her daily ball of rice with a broomstick. Grains reverberated off her kitchen walls and were spit onto the ground. Like heaps of white snow on hot asphalt, the magic liquified and from then on rice had to be grown by hand, with knees submerged in water. This was a vulnerable position to work from, for any body type, with limited visibility and muddy traction.
And so the Chinese imperialists came in, and stayed for over 1000 years, directing these bodies from the shores of drier land which offered misty panoramic views. The French did not arrive until 1887, but when they did, they quadrupled the amount of territory designated to rice growing by drowning solid ground previously being used to live on.
There is a specific kind of poverty, which is the kind that forces you to mine your own sustenance so deeply to the point where you don't know how to take sustenance when it is being given to you, because you are so used to giving it over. Today, rice is one of the country's top exports. Rice persists as the cause, the symptom, and the cure. Rice is born and dies and rebirths in literal wetness, elastic only to itself as individual grains, and continually yields as a collective stickiness, clinging to one another from within the shells of hegemonic shapes, but also deforming them through an inherent malleability.
We almost never meet one another at the right time, in the right bodies, and if we do the moment is so brief we spend the rest of our lives attempting to recreate it, the very attempt at which takes us in a direction further away from where we started. The bánh mì, in postcolonial terms and at this perspective in time, might be described as a hybridity. Within the framework of genetically modified foods and a western canon that enables eugenic processes, it's crucial to clarify that hybridity does not consist of two distinct lines intertwining like strands of DNA, fusing into an eternal code. There is nothing so primordial about your cultivated taste buds that could have validated the formation of the bánh mì, and yet prevented the popularization of central region foods, which are sometimes so slippery it feels like parts haven't died yet. The baguette cushions your cheeks from the impact of overwhelming flavor, a different life.
I can't allow you to romanticize the meeting of the French and the Vietnamese, because hybridity is not about reproductive sex. Hybridity is rather an impotence that glides along the form of an asymptote, which can be visualized as two lines getting closer and closer to one another but never being able to touch as they arch toward infinity. The recognition of hybridity is standing in this gap which grows all the more tragic the smaller it becomes, but also it is within this gap where we can see the other without losing ourselves. Loneliness is a predicate for seeing. The moment you speak about something it has separated from you. When your mouth is full and chewing you cannot speak. We eat to lose ourselves, to consume the literal body of the other, or our great grandparents. We claim eating is supposedly not intellectual, eating is instinct, which makes us animals, whom we rely upon for our humanness as we eat them. Eating is a reminder that we can die, which is expelled in the exhale of most satisfying pleasures.
As another French hybridity, phở is certainly the most popular Vietnamese American fare, sometimes valorized for its health benefits. But one might recall that the bone broth which gives phở its savorable depth was born out of the necessitation of using every part of the animal or else there wouldn't be enough, letting the creaturely bits simmer while the people slept, to eradicate the kind of bacteria that arises from not being able to manage disparate moments of decay, of having someone else's time imposed on you, of always running behind, of being left with the scraps. There are no heroics to this sort of urgency, no particular moment of revelation, just time passing by and allowing the unfamiliar parts to stew long enough so that they are eventually digestible, carried through the mundane and generous elasticity of a soup. Within this mixture of oxtail and cinnamon, swimming with rice noodles, is the taste of desperation and resilience and surrender and comfort and devastating victory after 1100 years of being called by a different name.
Now, from here, with no imminent threat, phở performs with each iteration for us as the motherland. A sip of broth is atemporal, as is your mother who never stops being your mother no matter how old she gets, how cruel she is, or how you are convinced that you are nothing like her, if you choose to see her only once a year, on the coldest day, and your mouth turns away the soup she makes you, it's because you won't allow her to claim innocence under the guise of cultural transmission.
Some things that my mother made me as a child growing up in America:
orange juice swirling in milk
vanilla ice cream baguette
spaghetti sauce with canned pineapple chunks
carved out watermelon domes filled with rice
escargot porridge
the entire surface of a birthday cake covered in peanuts when I asked for sprinkles
Diane Severin Nguyen is an artist who uses photography and time-based media to transform natural and inanimate objects into something uncanny. She currently lives and works between Los Angeles and New York. Nguyen earned an MFA from Bard College in 2020 and a BA from Virginia Commonwealth University in 2013. Her work will be included in the recent exhibition MADE L.A. 2020: a version, at the Hammer Museum, Los Angeles. She has had solo exhibitions at Bad Reputation, Los Angeles (2019) and Empty Gallery, Hong Kong (2019). Her film TYRANT STAR has screened at Yebisu Festival, Tokyo (2020); IFFR Rotterdam, Netherlands (2020); and the 57th New York Film Festival, New York (2019).
www.bureau-inc.com


Tampere United is a Finnish football club from the city of Tampere. The club plays in Kakkonen, the third highest level of football in Finland. The club had a team in Veikkausliiga, the premier football league in Finland, until the end of the 2010 season. It was excluded from participating in Finnish football during the 2011 season amidst suspicions of money laundering. The club was kept alive by its supporters, who entered a team called TamU-K in Kutonen, the lowest level of football in Finland, in 2012. The club earned three promotions in four years, and all its teams were taken over by Tampere United in the lead up to the 2016 season. Tampere United is now a fan-owned club and controlled by the same supporters who ran TamU-K.
The club was formed in July 1998. The initial plan was to join two local football clubs FC Ilves and TPV but TPV decided to continue as its own team. FC Ilves continued to play in lower divisions and Tampere United inherited its place in the second highest division.
In their first season, 1999 they won promotion to the top division, 15 months after the formation of the club. During season 2000 they reached sixth place in the league. In their third season 2001 they won the Finnish championship. In 2002, they finished in fifth place, and in 2003, third place. In 2006, Tampere United won their 2nd Finnish Championship and one year later, in 2007, they were the champions yet again taking home their 3rd title.
During the 2007 season, Tampere United also reached the third qualifying round of the Champions League. Tampere defeated Bulgarian champions Levski Sofia 2–0 on aggregate in the second qualifying round. Tampere United failed to reach the Champions League group stage when Rosenborg BK defeated them 5–0 on aggregate. In the UEFA Cup first round, United lost to Bordeaux 4–3 on aggregate.
On 14 April 2011 the club were suspended indefinitely by the Football Association of Finland because they had received money from a dubious company based in Singapore, known for involvement in fixed games and money laundering. The club was excluded from the 2011 season of Veikkausliiga. Players under contract were released due to lack of funds.
The club did not participate in any league in 2012 or 2013. In April 2013 the Turku Court of Appeal found the former CEO Deniz Bavautdin and the former Chairman of the Board Harri Pyhältö guilty of money laundering. At the moment the future of the club is unclear.
In the lead up to the 2016 season, Tampere United took over all the teams that played under TamU-K. Thereby the first team played in Kolmonen in 2016, and after the season it got promoted Kakkonen. In 2017 Tampere United finished sixth in Kakkonen Group B, and remains in Kakkonen in the 2018 season.
^ "New beginnings". When Saturday Comes. December 2012. p. 35.
^ Negrin, Matt (1 May 2014). "Fans Lose Soccer Team, Then Build Their Own". The New York Times. Retrieved 1 May 2014.
Tampereen Pallo-Veikot or TPV is a Finnish football club, based in Tampere. The club plays in the Kakkonen, the third highest level of football in Finland and it is the second largest football club in the Pirkanmaa region in terms of active members, with 1,600 members in 2005. The club was founded in 1930 as a sports club for workers. In the past there were bandy and ice hockey sections, in the 1960s TPV played three seasons at the highest level of Finnish ice hockey. Before the 1950s the clubs of Finnish Workers Sports Federation played in their own leagues that were not connected to the Football Association of Finland, tampereen Pallo-Veikot won the Finnish Workers Sports Federation championship six times. TPV joined the Finnish FA and competed at the highest level in the top tier of the Finnish football league system for five seasons in 1971, 1993–1995 and 1999. The most successful year was in 1994 when the won the Finnish Championship. In 1999 the club regained its Veikkausliiga status, but this lasted for one season.
Tampere is a city in Pirkanmaa, southern Finland. It is the most populous city in any of the Nordic countries. The city has a population of 223,292 growing to 313,058 people in the urban area, Tampere is the second-largest urban area and third most-populous individual municipality in the country, after Helsinki and Espoo municipalities. Its the most populous Finnish city outside the Greater Helsinki area and inner Finlands major urban, Tampere is between two lakes, Näsijärvi and Pyhäjärvi. Since the two differ in level by 18 metres, the rapids linking them, have been an important power source throughout history. Tampere is dubbed the Manchester of Finland for its industrial past as the center of Finnish industry. Helsinki is approximately 160 kilometres south of Tampere, and can be reached in 1.5 hours by train and 2 hours by car, the distance to Turku is roughly the same. Tampere–Pirkkala Airport is Finlands third-busiest airport, with over 400,000 passengers annually, there have been many debates on the origin of the name Tampere.
One theory is that it comes from the Swedish word damber, other suggestions have been the Swedish tamper-dagar, fasting days, and the Finnish word tammi. Although the name Tampere or its Swedish counterparts Tammer- part cannot be completely confirmed, Tampere was founded as a market place on the banks of the Tammerkoski channel in 1775 by Gustav III of Sweden and four years later,1 October 1779, Tampere was granted full city rights. At this time, it was a small town, consisting of only a few square kilometres of land around the Tammerkoski. Tampere grew as a market town and industrial centre in the 19th century. The towns industrial nature in the 19th and 20th centuries gave it the nickname Manchester of the North, Tampere was the centre of many important political events of Finland in the early 20th century. On 1 November 1905, during the strike, the famous Red Declaration was proclaimed on the Keskustori. In 1918, when Finland had recently gained independence, Tampere played a major role, Tampere was a red stronghold during the war, with Hugo Salmela in command.
Tammelan Stadion is a football stadium in Tampere, Finland. The stadium holds 5,060 people and was built in 1931 and it is the home ground for the Veikkausliiga club Ilves, the Kakkonen side TPV, and Ilves-Kissat, which plays in Kolmonen. The Ilves women's team, which plays in the Naisten liiga, the stadium's history began in 1926 when the city council made a decision to build a football field in Tammela. Construction, advanced rather slowly due to a lack of funds, the situation worsened during the recession of the late 1920s and early 1930s. The field was opened in 1931, but a look was reached only in 1937 when the first stand was built. The current stands were built in 1993, only the main stand has numbered seats,1300 in all. The attendance record for the stadium was set in October 2,1994, the current stadium does not meet the requirements set by Veikkausliiga, and a new one is being planned to replace it. The city of Tampere held a competition in 2014, in which a proposal called Hattutemppu by JKMM Arkkitehdit was chosen as the basis for the development project.
PFC Levski Sofia, commonly known as Levski Sofia, is a professional association football club based in Sofia, Bulgaria. The team competes in the First League, the top division of the Bulgarian football league system, Levski have participated in more seasons of the Bulgarian football championship than any other team, and are the only Bulgarian team to have never been relegated. They have won 73 trophies including 26 A Group titles,25 Bulgarian Cups and 3 Super Cups, on an international basis, Levski have reached three European Cup Winners Cup quarter-finals and two UEFA Cup quarter-finals. In 2006-07, they became the first Bulgarian club to reach the group stages of the UEFA Champions League. The teams regular kit colour is all-blue, Levskis home ground is the Vivacom Arena - Georgi Asparuhov Stadium in Sofia, which has a capacity of 25,000 spectators. The clubs biggest rivals are CSKA Sofia, and matches between the two sides are commonly referred to as The Eternal Derby of Bulgaria. Levski is a member of the European Club Association.
Sport Club Levski was founded in 1911 by a group of students at the Second Male High School in Sofia, the clubs name was chosen in honour of the Bulgarian revolutionary Vasil Levski, and the club was officially registered on May 24,1914. In 1914 Levski lost its first official match against FC13 Sofia by 0–2, in that period football wasnt a popular sport in Bulgaria, so there isnt any other information from the period concerning the club. In the summer of 1921, the Sofia Sports League was founded and it united 10 clubs from Sofia, marking the beginning of organized football competitions in the city. The Blues won the first match in the championship for the season 1921–22, held on September 18,1921, Levski captured the first place in the league in 1923 after a dramatic 3–2 win over bitter rival Slavia Sofia and successfully defended the title in the following season. The first National Championship was held in 1924 with Levski representing Sofia, the team went on to win the title in 1933,1937 and 1942, and established itself as the most popular football club in Bulgaria.
A panoramic view from the Clay Shaw Butler Stand.
Alain Giresse, influential Bordeaux player in the '70s and '80s and the club's all-time top scorer.
Skála has also a team in the women's best division, here they play against FC Suðuroy.
Mirko Vučinić began his career at Sutjeska.


This is a placeholder page for Alex Levinar, which means this person is not currently on this site. We do suggest using the tools below to find Alex Levinar.
You are visiting the placeholder page for Alex Levinar. This page is here because someone used our placeholder utility to look for Alex Levinar. We created this page automatically in hopes Alex Levinar would find it. If you are not Alex Levinar, but are an alumni of Land O Lakes High School, register on this site for free now.


Even if your requirement for chemical dosing is particularly unusual or unique, it is possible that we have equipment available that can be modified or altered to suit your needs. For example, we have an electro-chlorination container unit capable of producing 1000g/hr of Chlorine that was developed for emergency hire use for Nuclear Submarine biofouling control. This same unit has also been utilised for such diverse uses as temporary Chlorine dosing for a large municipal swimming pool and then for disinfection of a power station cooling water feed.
The hire fleet includes a wide range of individual pumps, chemical tanks & bunds with the capability to be used stand-alone or combined to meet specific process requirements. Tanks are available in a range of materials and sizes from small dosing tanks up to 25,000 litre ISO tanks and all with bunds to suit. The fleet includes a diverse range of chemical pumps including digital diaphragm, peristaltic and air operated diaphragm types. These main items are supported by a large stock of ancillary, valves, gauges and dosing lines.
The Hire division has over 50 WES DosingCubes on the hire fleet. The DosingCube™ enclosure is small enough to be portable with dose rates up to 150 L/hr. Comprising a weatherproof polyethylene rotationally moulded enclosure and utilising compact high–quality digital dosing pumps which have a user interface that lets you enter the dosing rate you want directly on the screen. With a very wide turndown ratio (100:1 for smaller pumps 800:1 for large pumps) there's no need for complicated stroke rate calculations. The DosingCube™ is truly plug & play.
The hire fleet includes a range of packed complete chemical dosing units comprising: tanks, bund, dosing pumps, piping, valves and control systems. The range includes the WES standard DS200, DS1200, DS1500 & DS5000 units and also includes a number of ISO container–based units and electro-chlorination systems for on-site manufacture of Sodium Hypochlorite. With storage sizes ranging from less than 100 litres to over 10,000 litres and system options including duty/standby systems, proportional dosing, pH correction, disinfection, emergency Oxygenation, etc.


text:
Italians in the Major Leagues
Bats approval
Team Italy gets first win in Europe-Africa Olympic Baseball Qualifier with 5-1 victory over Czech Republic
After the Europe-Africa Olympic Baseball Qualifier opener against South Africa was suspended due to inclement weather without a winner declared, Team Italy defeated Czech Republic 5-1 for its first victory of the five-day international tournament at Stadio Gianni Falchi in Bologna on September 19, 2019. Team Italy three-hole hitter Chris Colabello hit a sacrifice fly RBI in the bottom of the first inning and slammed a three-run blast over the left field fence in his next at-bat to put the game away for the Azzurri baseball squad.
Team Italy manager Gilberto "Gibo" Gerali used Bolzano right-hand pitcher Angelo Palumbo to start the game against the Czechs. The 23-year-old hurler surrendered one run in the top of the first inning. Team Italy answered and tied the contest 1-1 in the bottom of the first inning after Azzurri third baseman Drew Maggi led off with a single and later scored on a sacrifice fly by Team Italy slugger Chris Colabello.
The Italian offense came to life in the bottom of the third inning with a three-run rally to take a comfortable 4-1 lead. After Drew Maggi was walked and Alessandro Vaglio was hit by a pitch, Azzuri RBI machine Chris Colabello clubbed a three-run home run to left field. Team Italy added another run in the bottom of the fifth inning to increase the advantage to 5-1 when Drew Maggi singled and later crossed the plate on an RBI single by designated hitter Giuseppe Mazzanti, who collected a total of three hits on the night.
Despite going hitless with one walk, shortstop Gavin Cecchini demonstrated power at the plate in separate at-bats when two bombs he crushed over the left field fence were ruled foul and were not reflected in the box score. He was unlucky again in the bottom of the sixth inning when he was robbed of a base hit after the Czech center fielder made a spectacular diving catch.
In the top of the sixth inning with runners on the corners and one out, Team Italy pitching coach Dennis Cook made a visit to the mound to check on Angelo Palumbo. The Italian-Venezuelan starting pitcher remained in the contest and induced a 5-4-3 double play to end the scoring threat. Angelo Palumbo threw six innings and allowed just one run on seven hits with two strikeouts and one walk before handing off the ball to reliever Nick Pugliese, who entered the game in the top of the seventh inning with a runner on first base and no out. A single and a walk loaded the bases for Czech Republic, but two strikeouts and a fly out halted any possible comeback.
Nick Pugliese returned to pitch a scoreless top of the eighth inning. Team Italy captain and second baseman Alessandro Vaglio was responsible for two of the three outs when he charged two lightly-hit grounders up the middle and fired strikes to first baseman Chris Colabello. Filippo Crepaldi closed out the game in relief with three strikeouts and one single to secure the Team Italy 5-1 victory.
The Italians return to Stadio Nino Cavalli in Parma for a doubleheader on Friday, September 20 beginning in the morning at 11 am for the continuation of the suspended game against South Africa followed by the nightcap against Israel at 8 pm. Team Italy remains in Parma for a game against Spain on Saturday, September 21 at 8 pm. The rematch between European baseball powerhouses Italy and Kingdom of the Netherlands takes place at Stadio Gianni Falchi in Bologna on Sunday, September 22 at 8 pm. The top finisher in the round-robin tournament earns the right to be the lone Europe-Africa representative in the 2020 Tokyo Olympics. Forza #Italia! #LetsMakeItHappen #RoadtoTokyo
by Roberto Angotti
Czech Republic-Team Italy Box Score
Team Italy Photo Gallery
WBSC Europe-Africa Olympic Qualifier Schedule/Results
Team Italy and South Africa tied 4-4 in weather-related suspended Europe-Africa Olympic Baseball Qualifier opener
Team Italy baseball brothers Gavin Cecchini, Drew Maggi, and John Andreoli are ready to shine in Europe-Africa Olympic Baseball Qualifier
Groups for U18 and U12 European Baseball Championships revealed
CON6 Extra Inning Screening of Field of Dreams with actor Dwier Brown in Rimini
Fortitudo Bologna and ASD Nettuno Baseball City compete in 2020 European Champions Cup
Italy Experience Softball Camp comes to Concordia University in Irvine

redpajama_set_name: RedPajamaCommonCrawl


but i want background to be consistent so i decided get pics of the mods from their renderworlds... so can u guys help me...?
Your not going to get Jesussheep's.
Maybe you can arrange the mods from oldest to newest. And Anulot has recieved his mod item.
You know, some mods quit before the Render World feature was even added, so you won't be able to find them.
In thought they were purple orbs, lol.
Actually, you can find most mods and pics on the wiki, just download them from there, delete the original background and add the bedrock background.
Which pixelmorph do you guys think is better?
The one with the leaf board was the set i last saw him in.
all i can say is that his sets were great haha.


Elegant table linens that can be used for every day. Made from Irish linen with exquisitely sewn accents, these placemats and napkins are stocked in 10 beautiful colors, including a variety of classic neutrals and jewel-toned brights. Classic and contemporary, the Square Mat is stocked in white with a colored trim. Try it as a uniform set paired with our Satin Stitch or Border Napkin, or mix up colors and styles from this collection for a playful option that's uniquely your own.
Colours: Antique Gold, Celadon, Classic Grey, Cream, Emerald, Ice Blue, Oat, Sapphire, Sky Blue & Smoke Grey.
Size Classic Grey Placemats - Set of 4 - 14.5 x 14.5" Ice Bue Placemats - Set of 4 - 14.5 x 14.5" Oat Placemats - Set of 4 - 14.5 x 14.5" Sapphire Placemats - Set of 4 - 14.5 x 14.5" Sky Blue Placemats - Set of 4 - 14.5 x 14.5" Smoke Grey Placemats - Set of 4 - 14.5 x 14.5"
Classic Grey Placemats - Set of 4 - 14.5 x 14.5"
Ice Bue Placemats - Set of 4 - 14.5 x 14.5"
Oat Placemats - Set of 4 - 14.5 x 14.5"
Sapphire Placemats - Set of 4 - 14.5 x 14.5"
Sky Blue Placemats - Set of 4 - 14.5 x 14.5"
Smoke Grey Placemats - Set of 4 - 14.5 x 14.5"


text:
Chicago Sun-Times Voices Rite of Spring Concerts to Feature Stunning Visual
"Rite of Spring" Concerts in Millennium Park to Feature Stunning Visuals
by Hedy Weiss, Chicago Sun-Times Voices, The Daily Sizzle
Herbert Migdoll, the photographer responsible for helping create the image of the Joffrey Ballet back in the 1960s, and the man who continues to capture the company's dancers in mid-flight, also is a hugely gifted artist. And this Friday (Aug. 16 at 6:30 p.m.) and Saturday (Aug. 17 at 7:30 p.m.), two of his grand scale murals will serve as the visual accompaniment to performances by the Grant Park Orchestra and Chorus — one for "The Rite of Spring," the Igor Stravinsky masterwork, and another for John Adams' "Black Gondola."
"Leigh Levine, director of the Grant Park Music Festival, wanted 'The Rite of Spring' to have a visual component to celebrate its 100th anniversary," said Migdoll. "She decided to incorporate two of my works that join the arts of music and painting. And I am so thrilled and honored that my painting, 'The Chose One,' which was originally created with support from Barbara and David Kipper, was selected to hang directly over the orchestra. A second work, 'Black Gondola,' will appear below the orchestra."
This will be the final concert of Grant Park's 79th summer season, and in addition to "Rite" and "Black Gondola," Adams' work, "Harmonium" (a visionary choral setting of poems by John Donne and Emily Dickinson), will be part on the program to be conducted by Carlos Kalmar, with Donald Nally as guest chorus director.
Source >


The Gazella team will be packing up our bags and headed to St. Louis to pitch at the Midwest Digital Marketing Conference on April 12th and 13th. Over 2000+ digital marketers are expected to be at the conference located at the historic St. Louis Union Station .
The conference could not have came at a better time. Gazella is excited to be launching our White Label Wifi Marketing solution at the conference. The new option is the perfect solution for digital marketers, internet service providers, restaurant consulants, social media experts, and more.
During the conference Gazella will be offering our white label solution at a discounted price with additional support options. Click here for more information on plans and pricing for the Gazella White Label Wifi Marketing System.
To find out more about adding white label wifi marketing to your product line.Click here.


text:
Log in via BCS
A novel discharge risk model for patients hospitalised for acute decompensated heart failure incorporating N-terminal pro-B-type natriuretic peptide levels: a European coLlaboration on Acute decompeNsated Heart Failure: ÉLAN-HF Score
PDF +
Khibar Salah1,
Wouter E Kok1,
Luc W Eurlings2,
Paulo Bettencourt3,
Joana M Pimenta3,
Marco Metra4,
Antoni Bayes-Genis5,
Valerio Verdiani6,
Luca Bettari4,
Valentina Lazzarini4,
Peter Damman1,
Jan G Tijssen1,
Yigal M Pinto1
1Heart failure Research Center & Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
2Department of Cardiology, University Hospital Maastricht, Maastricht, The Netherlands
3Department of Internal Medicine, Hospital S. João, University of Porto Medical School, Porto, Portugal
4Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy
5Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
6Department of Internal Medicine and Emergency, Careggi University Hospital, Florence, Italy
Correspondence to K Salah, Heart Failure Research Center, Meibergdreef 9, F3-105, Amsterdam 1105 AZ, The Netherlands; k.salah{at}amc.uva.nl
Background Models to stratify risk for patients hospitalised for acute decompensated heart failure (ADHF) do not include the change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels during hospitalisation.
Objective The aim of our study was to develop a simple yet robust discharge prognostication score including NT-proBNP for this notorious high-risk population.
Design Individual patient data meta-analyses of prospective cohort studies.
Setting Seven prospective cohorts with in total 1301 patients.
Patients Our study population was assembled from the seven studies by selecting those patients admitted because of clinically validated ADHF, discharged alive, and NT-proBNP measurements available at admission and at discharge.
Main outcome measures The endpoints studied were all-cause mortality and a composite of all-cause mortality and/or first readmission for cardiovascular reason within 180 days after discharge.
Results The model that incorporated NT-proBNP levels at discharge as well as the changes in NT-proBNP during hospitalisation in addition to age ≥75 years, peripheral oedema, systolic blood pressure ≤115 mm Hg, hyponatremia at admission, serum urea of ≥15 mmol/L and New York Heart Association (NYHA) class at discharge, yielded the best C-statistic (area under the curve, 0.78, 95% CI 0.74 to 0.82). The addition of NT-proBNP to a reference model significantly improved prediction of mortality as shown by the net reclassification improvement (62%, p<0.001). A simplified model was obtained from the final Cox regression model by assigning weights to individual risk markers proportional to their relative risks. The risk score we designed identified four clinically significant subgroups. The pattern of increasing event rates with increasing score was confirmed in the validation group (BOT-AcuteHF, n=325, p<0.001).
Conclusions In patients hospitalised for ADHF, the addition of the discharge NT-proBNP values as well as the change in NT-proBNP to known risk markers, generates a relatively simple yet robust discharge risk score that importantly improves the prediction of adverse events.
http://dx.doi.org/10.1136/heartjnl-2013-303632
Heart failure (HF) is a major and growing public health problem in developed countries with a prevalence of about 0.4–2.2%.1 ,2 Particularly patients admitted for acute decompensated HF (ADHF) have high morbidity and mortality rates, most conspicuously in the first months after discharge. Worrisome readmission rates approaching 30–60% within 6 months have been reported.3 Accurate predictions of events after HF admission would be important to design targeted strategies at those with the highest risk of adverse events. Plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) or B-type natriuretic peptide (BNP) are established indicators of the diagnosis of HF4 ,5 and also allow predicting HF morbidity and mortality.6 More specifically, previous smaller studies in patients admitted for ADHF showed that discharge NT- proBNP levels predicted further events; lower levels of NT-proBNP at discharge are related to better outcome on a population level.4 ,7–11
Prognostication of patients is useful in allowing clinicians to triage patients during and after hospitalisation,12 ,13 and can also be used to select patients at high risk in whom the use of potent new therapies could be tested. Established models for risk stratification of patients admitted for ADHF do not employ the change in NT-proBNP during hospitalisation, because no studies of sufficient size have been available where NT-proBNP has been measured at admission and at discharge.14–18 Hence, we pooled individual patient data from several studies to develop, test and asses the clinical benefits of a discharge risk stratification model for evaluation of patients hospitalised for ADHF.19–21 Our aim was to develop a new, simple discharge risk score, using NT-proBNP values during hospitalisation and at discharge, to provide a tool that potentially could be applied in clinical settings.
Source populations
We searched for prospective studies of patients hospitalised for ADHF with NT-proBNP measurements at admission and at discharge (Medline/Embase, PubMed, and Cochrane). We found 357 abstracts in total. After removing all duplicate abstracts found in the different databases (29 abstracts) and narrative reviews, letters, editorials, comments and the like (109 abstracts), we ultimately reviewed 219 abstracts. A more explicit detail on the search and data collection has been added as an online supplementary appendix (eAppendix 1).
We identified five prospective cohort studies eligible for inclusion.7–9 ,22 ,23 Additionally, on the basis of our personal contact, we knew of two Dutch cohorts of patients hospitalised for ADHF. The first cohort was part of a registry at the Academic Medical Center (AMC) in Amsterdam. The second cohort consisted of patients screened for the PRIMA study.24 Furthermore, we identified one more published study at the time we were collecting our data on the basis of the bibliographies of expert advisors.11 All cohorts were registries, and patients were admitted for ADHF, in whom NT-proBNP concentrations had been measured at admission and at discharge. All studies were approved by the ethical commission in their respective centres. For the conduction of the current study, we received the approval of the ethical commission. The principal investigators of seven of the eight studies7–9 ,11 ,23 ,24 agreed to perform a collaborative analysis. The flow diagram for selection of articles is shown in figure 1.
Flow diagram for selection of articles. aHalf the cohort was excluded, because of duplicated data. bWe excluded 40% of the original cohort, because of missing follow-up data.
Our study population was assembled from the seven cohorts by selecting those patients that satisfied the following inclusion criteria: (1) admitted because of clinically validated ADHF,25 (2) discharged alive and (3) NT-proBNP measurements available at admission and at discharge. We excluded 51 patients of the Verdiani et al11 cohort from our analysis, because no follow-up was available. We also removed duplicate reports of the same patients (n=147) in the Bettencourt et al8 and Pimenta et al23 cohorts from the analyses. Eventually, our cohort consisted of 1301 patients. Because of the above exclusions, the numbers of patients reported here may differ from those in the original publications.
The primary endpoint of this study was time till death from any cause within 180 days. The secondary endpoint was time till death from any cause, or time till the first readmission for cardiovascular reason within 180 days. The relations of NT-proBNP to death from all causes, and to the composite endpoint, were investigated with the use of Kaplan–Meier curves (KM-curves), compared with Log Rank test, and the use of Cox proportional hazards regression in univariable and multivariable analyses. In these models, we evaluated the effect of absolute NT-proBNP levels at discharge according to cut-off levels based on quartiles among those who died (<1500 pg/mL, 1500–5000 pg/mL, 5001–15 000 pg/mL, and >15 000 pg/mL). The effect of NT-proBNP reduction percentage was evaluated using dichotomised (≤30%) which was derived as the median percentage reduction in NT-proBNP among those who died and which was also confirmed in a ROC-analysis (area under the curve (AUC) 0.68, 95%CI 0.64 to 0.72) of NT-proBNP reductions on mortality (data not shown). It should be noted that for the calculation of the risk estimate and for the calculation of the Kaplan–Meier curves, we did use the whole population. For cTnT, a prospectively defined upper reference limit of 0.05 μg/L and a lower limit of 0.03 μg/L were used for statistical analysis. The cut-off levels for anaemia (haemoglobin <129 g/L (8 mmol/L) in men; <121 g/L (7.5 mmol/L) in women), hyponatremia (sodium <135 mmol/L), and estimated Glomerular Filtration Rate (eGFR) (≤30 mL/min/1.73 m²) are based on European Society of Cardiology (ESC) guidelines,26 and the cut-off levels for systolic blood pressure (SBP ≤115 mm/Hg) and serum urea (≥15 mmol/L) levels are based on previously published risk stratification analyses in patients hospitalised for ADHF.15 ,16
A total of 24 admission and discharge characteristics arranged in a dichotomous fashion were screened as candidate predictor variables of 180-day mortality. These variables were included based on previous research and based on their clinical relevance.1 ,4–11 13–18 ,22 ,23 ,26–32 Each factor was tested independently in a univariable Cox regression model, and all variables considered were added in a multivariable model to assess the statistical significance and reliability of NT-proBNP levels. Thereafter, a multivariable stepwise (backward elimination) Cox regression model was used to build the final model. Variables associated with p value less then 0.05 by the Wald statistic were retained in the model. To check for the proportional hazards assumption we used the log-minus-log function, and in the presence of non-proportionality, we considered the HRs as the average HR for a predictor over the follow-up period. Furthermore, separate baseline hazard functions were used for the different cohorts to adjust for between-study differences. To confirm our final model, a bootstrapping method was performed. Data were resampled 1.000 times, fitting a Cox regression model with backward selection technique in a stepwise manner. The predictive performance of the model to classify patients was evaluated using the C statistic (area under the receiver operating characteristic curve). To estimate the additional discriminative value of NT-proBNP cut-off levels, we calculated the C-statistic for the models with and without the addition of NT-proBNP levels. To further quantify this discriminative power, we used the method previously described by Pencina et al.33 We analysed differences in patients' individual estimated probability after addition of NT-proBNP cut-off levels as categorical variable to a referent model containing the previously identified baseline clinical characteristics. For the net reclassification improvement (NRI), each probability increase would imply improved prediction ability, whereas the opposite would imply worse prediction ability. We also calculated the integrated discrimination improvement (IDI), which directly compares the mean difference in probability between models with and without the addition of NT-proBNP cut-off levels.
Moreover, we investigated the additional predictive value of the decrease in NT-proBNP during hospitalisation on top of the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterisation Effectiveness) Risk Model and Discharge Score in a bivariable Cox regression model. A more explicit detail on this analysis and the results has been added as an online supplementary appendix (eAppendix 2).
The multivariable Cox regression model was used to develop a predictive discharge score based on the strongest predicting variables regarding mortality and including NT-proBNP absolute values at discharge and percentage reduction. A simplified model was obtained by assigning weights to individual risk markers proportional to their regression coefficients. Cut-offs of the ÉLAN-HF Score (European coLlaboration on Acute decompeNsated Heart Failure) for the different risk groups were based on quartiles among those who had an event. However, it should be noted that for the calculation of the risk estimate and the calculation of the Kaplan–Meier curves, we did use the whole population.
The risk score was externally validated in a separate cohort of patients from the BOT-AcuteHF (NT-proBNP in the Optimisation of Treatment after recent Acute Heart Failure) trial (n=325, ClinicalTrials.gov Identifier: NCT00498472). The BOT-AcuteHF trial was designed to evaluate whether the assessment of NT-proBNP levels measured before discharge improves prognostication. This study enrolled patients between January 2006 and April 2010 who were admitted for ADHF with New York Heart Association (NYHA) Class III or IV and requiring intravenous therapy. Patients were randomly assigned to NT-proBNP guided treatment or standard care. The trial was recently completed but the results are yet to be published. In this study, NT-proBNP levels were measured at 3 days before discharge and at discharge. Hence, the change between values at discharge and those at 3 days before discharge was used as a proxy for the change parameter in our risk model. We calculated the KM curves for 1-year mortality for the four categories of our risk score.
Demographic characteristics are presented as frequencies and percentages when it concerns categorical data, and the Fisher exact test was used to make a comparison. Normally distributed, continuous variables are reported as mean±SD, and were compared using the Student t test. Other continuous data, expressed as median with IQR, were compared using the Mann–Whitney U test. Multiple imputation pooling algorithms was used to correct for missing values. All probability values were two-sided and considered significant if <0.05. Statistical analyses were conducted using SPSS V.19.0.1 (SPSS, Chicago, Illinois, USA) and R (R Foundation for Statistical Computing, Vienna, Austria).
Table 1 shows the baseline characteristics of the 1301 patients included in our study. The median age of the study population was 74 years, with 607 (47%) patients aged 75 years or older. Of the 1301 patients admitted for ADHF, 631 (49%) patients were known to have an ischaemic aetiology, 838 (72%) of the patients had an LVEF <45%, and 513 (43%) patients were diagnosed to have AF at admission. The median NT-proBNP value at admission was 6447 pg/mL and the median discharge NT-proBNP value was 3252 pg/mL. At discharge, 1156 (95%) patients received diuretics, 806 (66%) of the patients received an ACE-inhibitor, and 685 (57%) patients received a β blocker.
Baseline characteristics study population
Of the study patients, 195 (84 women and 111 men) reached the primary endpoint of the study (all-cause mortality), which was equal to a mortality of 15% at 180 days. Furthermore, 558 study patients (228 women and 330 men) reached the composite (all-cause mortality/cardiovascular readmissions) endpoint, which equals an event rate of 43%. Mortality and composite event rates, according to quartiles of absolute NT-proBNP values at discharge, are shown in figure 2A. The 180-day cumulative mortality was 4.1% among patients with an absolute NT-proBNP discharge level of <1500 pg/mL. This 180-day mortality more than doubled to 10% when the NT-proBNP discharge level was between 1500 and 5000 pg/mL, and again doubled to 24% when the NT-proBNP discharge level was between 5001 and 15 000 pg/mL. Patients with a NT-proBNP discharge level of >15 000 pg/mL had a mortality of 41%. The same pattern was also observed for the composite endpoint with the cumulative event rates of 28%, 43%, 53% and 63% for the four NT-proBNP absolute discharge levels, respectively.
Kaplan–Meier curves for all-cause mortality and composite endpoint at 180 days according to the quartiles of the absolute NT-proBNP values at discharge (A) and according to the dichotomised NT-proBNP percentage reduction during hospitalisation (B). NT-proBNP indicates N-terminal pro-B-type natriuretic peptide. Access the article online to view this figure in colour.
The relation between dichotomised 30% NT-proBNP reduction percentage and the outcome is shown in figure 2B. The 180-day cumulative mortality was twice as high among patients with a NT-proBNP reduction of ≤30% in comparison to the patients with a NT-proBNP reduction of >30%. This also applied to the composite event rate.
Univariable and multivariable Cox regression analyses are presented in table 2. In the multivariable analyses (table 2, right panel), NT-proBNP absolute values at discharge and NT-proBNP percentage reduction were predictors of death within 180 days, albeit with slightly attenuated HRs for the NT-proBNP absolute levels at discharge, as well as for the NT-proBNP reduction percentage during hospitalisation. Other independent risk markers were, age ≥75 years at admission, presence of peripheral oedema at admission, SBP ≤115 mm Hg at admission, hyponatremia at admission, serum urea of ≥15 mmol/L at discharge and NYHA class at discharge. According to our multivariable regression analysis, LVEF ≤25%, cTNT values at admission and eGFR ≤30 mL/min/1.73 m² at discharge were not independently associated with 180-day mortality. Table 3 shows the association of NT-proBNP levels to LVEF, eGFR and cTnT levels.
Univariable and multivariable Cox regression analysis for 180-day mortality
Association of NT-proBNP levels to LVEF, eGFR and cTnT
The C-statistics increased significantly (AUC 0.78, 95% CI 0.74 to 0.82 vs AUC 0.71; 95% CI 0.67 to 0.76, p<0.001) for the prediction of death from any cause within 180 days when NT-proBNP levels were added into a model with established risk markers. This also accounts for the model that uses the covariates with their raw uncategorised value (AUC 0.77. 95% CI 0.73 to 0.82). Furthermore, the addition of NT-proBNP levels contributed significantly (p<0.001) with a 62% NRI to the reference model containing clinical predictors; the NRI for events was 33% and the NRI for non-events was 29%. The IDI was 0.07; p<0.001, which consisted of IDI for events (0.06) and IDI for non-events (0.01).
Construction of ÉLAN-HF score
After assigning weights to individual risk markers proportional to their regression coefficients, the ÉLAN-HF Score could be calculated (table 4). The mortality increased significantly in a stepwise manner across the risk groups (table 5) of low (≤2 point), intermediate (3–4 points), high (5–7 points), and very high (≥8 points), which was also visualised in a Kaplan–Meier curve (figure 3A). The mortality for the intermediate risk group almost doubled to 9%, compared with the low-risk group (3.6%). This cumulative 180-day mortality doubled again to 23% for the high-risk group, and this compared with the very high-risk group more that doubled again to 51%. The composite event rate increased also in the same stepwise manner for the four risk groups as shown in figure 3B; low (28%), intermediate (39%), high (59%), and very high (70%). The C statistic for the simplified model was 0.76 (95% CI 0.71 to 0.80).
Calculation of ÉLAN-HF (European coLlaboration on Acute decompeNsated Heart Failure) score
Mortality rates for the ÉLAN-HF (European coLlaboration on Acute decompeNsated Heart Failure) score
Kaplan–Meier curves for All-cause mortality (A) and the composite endpoint (B) at 180 days and for all-cause mortality in the BOT-acuteHF at 1 Year (C) according to ÉLAN-HF Score. Event rates increased significantly as the risk score increased in both cohorts. ÉLAN-HF, European coLlaboration on Acute decompeNsated Heart Failure. Access the article online to view this figure in colour.
External validation of ÉLAN-HF score
The external validation of ÉLAN-HF Score in the BOT-AcuteHF population (n=325) is shown in figure 3C. The pattern of increasing event rates with increasing score was confirmed in the external cohort of BOT-AcuteHF trial. The 1-year all-cause mortality increased in a stepwise manner for the four risk groups with a rate of 7% for the low-risk patients, 13% for the patients with a intermediate risk, 24% for the patients with a high risk and 52% for the very high-risk patients (p<0.001).
The strong association between discharge plasma levels of NT-proBNP and adverse events in our study emphasises the important role of this biomarker for the prognosis of patients hospitalised for ADHF. We first determined optimally discriminative cut-off levels for NT-proBNP values at discharge as well as the percentage change during hospitalisation. Patients with higher levels of NT-proBNP at discharge, or an inadequate decline during hospitalisation, had a substantially higher risk of readmission and/or death within 180 days. Our results show that measurement of absolute NT-proBNP values at discharge, as well as the percentage reduction, adds important prognostic information to the initial evaluation of these patients and, therefore, should be considered as part of an early assessment of risk.
The risk markers
Previous studies have suggested that measurement of NT-proBNP can improve prognostication of patients admitted for ADHF.4 ,7–11 ,16 ,22 ,27 ,29 However, there has been an ongoing debate whether to use NT-proBNP values at discharge or the changes during hospitalisation in risk assessment.7 ,8 ,10 ,11 ,34 In our model, the absolute discharge NT-proBNP and the reduction percentage were entered and both proved to be the most powerful predictors of 180-day mortality. The incorporation of a combination of absolute NT-proBNP at discharge and percentage reduction levels into a model with established risk markers improved the risk stratification for adverse events within 180 days, as evidenced by a substantial and statistically significant increase in the C statistic, category less NRI and IDI.
Additionally, we included, age ≥75 years at admission, presence of peripheral oedema at admission, SBP ≤115 mm Hg at admission, hyponatremia at admission, serum urea of ≥15 mmol/L at discharge and NYHA class at discharge as independent risk markers in our multivariable model. Systemic hypotension has also been identified by others as a mortality predictor.15 ,16 ,31 ,35 Although higher SBP at admission was associated with a better outcome, it is clear that this does not necessarily mean that maintaining higher SBP during hospitalisation is beneficial. Higher SBP at admission may merely indicate that there is enough contractile reserve to allow a cardiac output and blood pressure response and, therefore, more room for therapeutic interventions, such as higher doses of β blockers and diuretics. Moreover, our results indicate once again the importance of hyponatremia and serum urea of ≥15 mmol/L in patients admitted for ADHF; previous studies have shown that regardless of the healthcare setting, ventricular function, or the timing of blood sampling, these biomarkers are associated with adverse events.15 ,16 ,30 ,36 Furthermore, established risk markers, such as LVEF ≤25%, cTNT values at admission and eGFR ≤30 mL/min/1.73 m² at discharge were not independently associated with 180-day mortality.8 ,9 ,16 ,31 ,37–39 This phenomena might, at least partly, be explained by the observation that NT-proBNP levels are strongly associated with LVEF, eGFR and cTnT levels in our study.
The regression model
An important difference between our model and other models used to predict HF mortality is the addition of sequential NT-proBNP measurement into the model. Five other regression models have been described for predict mortality in patients admitted for ADHF.14–18 However, two of these models were developed for in-hospital mortality and did not include postdischarge follow-up.15 ,18 Hence, this makes these models incomparable with our model. Of the remaining three models, two models were retrospective studies designed to predict mortality at 30 days16 ,17 and at 1 year.16 The fifth model, predicting mortality at 60 days, was limited to patients with left ventricular systolic HF, which does not represent the general population of patients admitted for ADHF.14 Patients with HF and preserved systolic function represent as much as 40% of the total HF population.40 Most importantly, unfortunately none of these previous models included NT-proBNP as a prognostic factor.
The ÉLAN-HF score
The variables used to construct ÉLAN-HF Score were derived from the Cox regression model that confirmed their independent predictive power after multivariate adjustment, incorporating for the first time the NT-proBNP levels at discharge and the reduction percentage in NT-proBNP during hospitalisation into the model. This simplified discharge risk score performs as well as the multivariable model, as evidenced by the marginal difference between the C-statistics. This also accounts for the model that uses the covariates with their raw uncategorised value. Hence, the simplification of the model does not imply a loss of information, and our risk score is a simple and effective way of classifying 180-day risk after discharge in patients hospitalised for ADHF. It goes without saying that the NT-proBNP level is the primary factor that drives the risk score. The patients with the lowest level are in the lowest categories of the risk score, while patients with the highest levels are in the highest categories. Nevertheless, the other risk markers in ÉLAN-HF Score do have a significant role, and they upgrade the patient at every stratum across the risk score to the next higher risk category. Recently, two risk models have been developed, including BNP values at discharge13 or the log of NT-proBNP level at discharge.41 However, both these models did not contain the changes of BNP or NT-proBNP during hospitalisation. Furthermore, one of these models was rather a small study, and the study population consisted only of patients with severe left ventricular dysfunction and advanced symptoms.13 Additionally, as the investigators of this study excluded patients with severe renal dysfunction and those requiring high doses of inotropes during hospitalisation, this could have altered the analysis, because these patients have worse outcome.13 ,14 The investigators of the other study developed a risk engine41 which was based on a complex modelling using continuous variables; all risk markers were treated as fixed-time covariates. They did not use straightforward cut-off levels, which make the risk engine complex and difficult to calculate. This makes the applications of the risk engine for clinical use unattractive and inconvenient. Thus, the strength of our model is its easy calculation, clinical application and broad applicability; it is applicable for patients with impaired as well as preserved LVEF, and regardless of therapies undergone during hospitalisation.
Validation of ÉLAN-HF score
ÉLAN-HF Score appears statistically robust in that the external validity of the risk score was confirmed in the validation cohort. It was validated in a separate cohort of patients from the BOT-AcuteHF trial. The observation of increasing 1-year mortality with increasing score confirmed the predictive proportional value of our risk score. Hence, ÉLAN-HF Score is a reliable risk score, which is predictive for death, and a composite endpoint of death and readmission within 180 days.
Several limitations of our analyses should be acknowledged. The current study was an individual patient data meta-analysis, which was conceived after publication of the original studies. As each of the original studies was a prospective cohort study with dedicated predesigned data collection, this retrospective aspect of the study does not compromise the validity of our analysis. However, variation in treatment and inclusion criteria in the different centres should be considered. Nevertheless, this spread in NT-proBNP and therapeutic approach of patients as observed reflects the day-to-day clinical practice. Missing data should be considered as a limitation in our study. However, we did correct for the bias from data missing at random by using multiple imputation pooling algorithms, and it should be noted that for our most important variable, NT-proBNP, static and dynamic values were almost completely available. NT-proBNP level at discharge is the most important variable in our analyses, and a model and was available in 99% (n=1289) of the patients. In 97% (n=1266) of the patients, the NT-proBNP change during hospitalisation could be calculated. The clinical interpretation of NRI, and even more of IDI, may be difficult. It should be mentioned that the sum of the differences in the proportion of patient moving up minus the patient moving down or vice versa, quantifies the improvement in reclassification. Hence, it is important for the clinical interpretation that risk categories closely linked to decision making should exist because the NRI is highly sensitive to the number and choice of risk categories. Furthermore, for the external validation cohort, the NT-proBNP values at admission were not available. Instead, we used NT-proBNP values obtained 3 days before discharge as a proxy to calculate the dynamics of NT-proBNP during hospitalisation. Additionally, we compensated the relatively small sample size in the BOT-AcuteHF cohort by extending the follow-up duration to 1 year. In spite of these limitations, the predictive proportionality of our model was confirmed in the validation cohort. The ÉLAN-HF Score we developed has been limited to studies using NT-proBNP, since these were most numerously available having admission and discharge values (eight studies available for NT-proBNP against two studies for BNP). Nevertheless, the principle advantages of our score (ie, incorporating dynamic changes in a natriuretic peptide) are very likely equally applicable to BNP. However, since NT-proBNP values cannot be directly translated to a BNP value, the precise BNP values in such a score would need large databases to ascertain these. A recent study with BNP, the model with BNP at discharge best predicts 1-year mortality and/or rehospitalisation. However, this was a retrospective study, and was done only among older patients hospitalised with HF.42
ÉLAN-HF Score offers several promising applications for clinical use. The strength of our model is its broad applicability and also its easy calculation. It is easy to recall and apply clinically since straightforward cut-off levels were determined in lieu of more complex modelling using continuous variables. Moreover, variables in the current predictive model can be easily ascertained when a patient is hospitalised for ADHF. Furthermore, the incorporation of ÉLAN-HF Score in clinical practice could be accomplished quickly, since the measurement of NT-proBNP is already well established. Other novel new biomarkers may provide additional prognostic information and may need to be incorporated in future refinements of the risk score, as such measurements become more widely available. Although introduction of weighting markers for predictor variables or expansion of the list of predictor variables may lead to improvement in statistical measures of the predictive performance of the model (eg, C statistic), this is likely to occur at the cost of a loss of simplicity. Risk score development requires judgment to determine when a model predicts a sufficiently large gradient of risk to be clinically useful, and further refinement of the model produces unattractive levels of complexity.
Our results indicate that a simple discharge risk score incorporating NT-proBNP values at discharge as well as the dynamic change in NT-proBNP during hospitalisation enables the clinician to categorise a patient's risk at discharge to predict the event rate of death and a composite endpoint of death and readmission within 180 days. The novelty of the ÉLAN-HF Score is that absolute values at discharge and the reduction percentage of NT-proBNP significantly contributed to the risk score in contrast to previous established models which used only one of them or none at all. Since patients hospitalised for ADHF are at increased risk of adverse events and death, it is important to assess prognosis on an individual basis to formulate plans for evaluation and treatment. Nevertheless, the choice of therapy among a wide variety of treatment options, ranging from conservative to highly aggressive treatment, is often the most challenging question. Identifying a high-risk patient may call for more aggressive treatment and also for a much closer follow-up, possibly in a HF management programme. Therefore, a robust discharge risk gradation can, importantly, support treatment decisions and would be useful in identifying patients who need short-term, specialised re-evaluation following admission for ADHF. ÉLAN-HF Score is a simple yet robust discharge score to prognosticate patients within this notorious high-risk population.
We would like to thank Dr. Nan van Geloven for her help with the statistical analyses.
Cowie MR,
Mosterd A,
Wood DA,
. The epidemiology of heart failure. Eur Heart J 1997;18:208–25.
Ho KK,
Pinsky JL,
Kannel WB,
. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol 1993;22:6A–13A.
Haldeman GA,
Croft JB,
Giles WH,
. Hospitalization of patients with HF: National Hospital Discharge Survey, 1985 to 1995. Am Heart J 1999;137:352–60.
van Kimmenade R,
Lainchbury J,
. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J 2006;27:330–7.
Maisel AS,
Krishnaswamy P,
Nowak RM,
. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347:161–7.
Hartmann F,
Packer M,
Coats AJ,
. Prognostic impact of plasma N-terminal pro-brain natriuretic peptide in severe chronic congestive heart failure: a substudy of the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) trial. Circulation 2004;110:1780–6.
Bayés-Genís A,
Lopez L,
Zapico E,
. NT-ProBNP reduction percentage during admission for acutely decompensated heart failure predicts long-term cardiovascular mortality. J Card Fail 2005;11:S3–8.
Bettencourt P,
Azevedo A,
Pimenta J,
. N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients. Circulation 2004;110:2168–74.
Metra M,
Nordari S,
Parrinello G,
. The role of plasma biomarkers in acute heart failure. Serial changes and independent prognostic value of NT-proBNP and cardiac troponin-T. Eur J Heart Fail 2007;9:776–86.
O'Brien R,
Squire IB,
Demme B,
. Predischarge, but not admission, levels of NT-proBNP predict adverse prognosis following acute LVF. Eur J Heart Fail 2003;5:499–506.
Verdiani V,
Ognibene A,
Rutili MS,
. NT-ProBNP reduction percentage during hospital stay predicts long-term mortality and readmission in heart failure patients. J Cardiovasc Med 2008;9:694–9.
Bhardwaj A,
Januzzi JL Jr.
. Natriuretic peptide-guided management of acutely destabilized heart failure: rationale and treatment algorithm. Crit Pathw Cardiol 2009;8:146–50.
O'Connor CM,
Hasselblad V,
Mehta RH,
. Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. J Am Coll Cardiol 2010;55:872–8.
Felker GM,
Leimberger JD,
Califf RM,
. Risk stratification after hospitalization for decompensated heart failure. J Card Fail 2004;10:460–6.
Fonarow GC,
Adams KF jr.,
Abraham WT,
. Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA 2005;293:572–80.
Lee D,
Austin PC,
Rouleau JL,
. Predicting mortality among patients hospitalized for heart failure: derivation and validation of clinical model. JAMA 2003;290:2581–7.
Rosenthal GE,
Baker DW,
Norris DG,
. Relationships between in-hospital and 30-day standardized hospital mortality: implications for profiling hospitals. Health Serv Res 2000;34:1449–68.
Selker HP,
Griffith JL,
D'Agostino RB
. A time-insensitive predictive instrument for acute hospital mortality due to congestive heart failure: development, testing, and use for comparing hospitals: a multicenter study. Med Care 1994;32:1040–52.
Stewart LA,
Tierney JF
. To IPD or not to IPD? Advantages and disadvantages of systematic reviews using individual patient data. Eval Health Prof 2002;25:76–97.
Parmar MKB
. Meta-analysis of the literature or of individual patient data: is there a difference? Lancet 1993;341:418–22.
Simmonds MC,
Higgins JP,
. Meta-analysis of individual patient data from randomized trials: a review of methods used in practice. Clin Trials 2005;2:209–17.
Kubler P,
Jankowska EA,
Majda J,
. Lack of decrease in plasma N-terminal pro-brain natriuretic peptide identifies acute heart failure patients with very poor outcome. Int J Cardiol 2008;129:373–8.
Pimenta JM,
Almeida R,
Araújo JP,
. Amino terminal B-type natriuretic peptide, renal function, and prognosis in acute heart failure: a hospital cohort study. J Card Fail 2007;13:275–80.
Eurlings LW,
van Pol PE,
Kok WE,
. Management of chronic heart failure guided by individual N-terminal pro-B-type natriuretic peptide targets: results of the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study. J Am Coll Cardiol 2010;56:2090–100.
McMurray JJ,
Adamopoulos S,
Anker SD,
. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2012;14:803–69.
Dickstein K,
Cohen-Solal A,
Filippatos G,
. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 2008;10:933–89.
Fonseca L,
. Prognosis of decompensated heart failure patients with preserved systolic function is predicted by NT-proBNP variations during hospitalization. Int J Cardiol 2007;117:75–9.
Logeart D,
Huang B,
. Lowered B-type natriuretic peptide in response to levosimendan or dobutamine treatment is associated with improved survival in patients with severe acutely decompensated heart failure. J Am Coll Cardiol 2009;53:2343–8.
Ferreira S,
Guerrero H,
. Prognosis of decompensated heart failure: role of NT-proBNP. Rev Port Cardiol 2007;26:535–45.
Gheorghiade M,
Albert NM,
. Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure: an analysis from the OPTIMIZE-HF registry. Eur Heart J 2007;28:980–8.
Harjola VP,
Fallath F,
Nieminen MS,
. Characteristics,outcomes,and predictors of mortality at 3 months and 1 year in patients hospitalized for acute heart failure. Eur J Heart Fail 2010;12:239–48.
Thabut G,
Jourdain P,
. Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure. J Am Coll Cardiol 2004;43:635–41.
Pencina MJ,
D'Agostino RB Sr.,
D' Agostino RB Jr.,
. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med 2008;27:157–72.
Richards M,
Troughton RW
. NT-proBNP in heart failure: therapy decisionsand monitoring. Eur J Heart Fail 2004;6:351–4. Eur J Heart Fail 2004;6:351–354.
Siirilä-Waris K,
Lassus J,
Melin J,
. Characteristics,outcomes,and predictors of 1-year mortality in patients hospitalized for acute heart failure. Eur Heart J 2006;27:3011–17.
Klein L,
O'Conner CM,
. Lower serum sodium is associated with increased short-term mortality in hospitalized patients with worsening heart failure: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study. Circulation 2005;111:2454–60.
Damman K,
Jaarsma T,
Voors AA,
. Both in- and out-hospital worsening of renal function predict outcome in patients with heart failure: results from the Coordinating Study Evaluating Outcome of Advising and Counseling in Heart Failure (COACH). Eur J Heart Fail 2009;11:847–54.
Ilva T,
Siirila-Waris K,
. Clinical significance of cardiac troponins I and T in acute heart failure. Eur J Heart Fail 2008;10:772–9.
Peacock WF,
De MT,
. Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008;358:2117–26.
Vasan RS,
Benjamin EJ,
Levy D
. Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol 1995;26:1565–74.
Postmus D,
van Veldhuisen DJ,
. The COACH risk engine: a multistate model for predicting survival and hospitalization in patients with heart failure. Eur J Heart Fail 2012;14:168–75.
Kociol RD,
Horton JR,
. Admission, discharge, or change in B-type natriuretic peptide and long-term outcomes: data from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) linked to Medicare claims. Circ Heart Fail 2011;4:628–36.
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 appendix 1
Contributors KS, WEK and YMP had the idea for the project, designed the collaborative analysis, and undertook searches of published work. KS collected the individual patient data and prepared for analysis. Statistical analysis and elaboration of figures was done by KS, PD and JGT. MM, LB and VL provided us the external cohort to validate the risk score. KS wrote the paper with important contribution from JGT, WEK and YMP, and input from PB, MM and AB-G. LWE, JMP and VV provided valuable comments on the report. All principal investigators shared individual patient data and had an opportunity to contribute to the interpretation of results and to the redrafting of the report. All authors reviewed and revised the manuscript, and approved the final version.
Competing interests LWE and YMP received research funding for their original study from the Dutch Heart Foundation, Dutch Organisation for Scientific Research (NWO), the Royal Dutch Academy of Arts and Sciences (KNAW)—Interuniversity Cardiology Institute of The Netherlands, Pfizer, Astra-Zeneca, Medtronic and Roche Diagnostics. YMP is a recipient of payments for lectures including service on speakers bureaus and research grants from ROCHE Diagnostics. YMP has an unrelated biomarker patent and stocks in a University spinoff company. WEK receives grants from the Dutch Heart Foundation for an unrelated study. PB receives consultancy payments from Boeringher-Inglenheim, grants from the FCT- Portugues Science Foundation and payments for lectures including service on speakers bureaus from Servier. MM is a member of the board in Corthera and Novartis and receives payment for lectures including service on speakers bureaus, from Servier or Stroder. AB-G receives payments for lectures including service on speakers' bureaus from Roche Diagnostics, Siemens and Rovi. All other authors have reported that they have no relationships to disclose.
Patient consent Obtained.
Ethics approval METC.
Highlights from the issue
Catherine M Otto
Heart 2013; 100 91-92 Published Online First: 30 Dec 2013. doi: 10.1136/heartjnl-2013-305324
Education in heart
Best Research Paper Award
Copyright © 2023 BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.


text:
Archaeologists solve Roman Empire mystery with 500 letters discovered near Hadrian's Wall
After discovering 500 stone tablets which reveal the mysteries of the Roman Empire, ARCHAEOLOGISTS resolved the 2000 year old mystery.
Neapolis was a major ancient city, founded by the Greeks of Cyrene as a trading port in the 5th century before it became a port when the Roman Empire conquered in North Africa.
The Roman Empire mystery was solved
Now, a city named Nabeul stands where the metropolis once existed, constructed over top of the most of remains, which made them inaccessible and likely mostly destroyed. However, researcher Mounir Fantar found several tanks in this ancient city in 2017, which led him to theorise that Neapolis was an exporter of a fish sauce known as garum.
Two years later, stone tablets discovered in Carlisle, Cumbria, during Channel 5's "Ancient Mysteries" series confirmed his suspicions.
The narrator said in October: "Neapolis was actually the epicentre for the mass production of fish sauce.
The Roman Empire in all its glory
"But how did its producers in Neapolis, on the southern boundary of the vast Roman world, manage to reach its markets thousands of miles away?
"The answer can be found in a unique collection of documents that suggest Neapolis was part of the ancient world's greatest supply chain, one that would power the Roman military machine as it conquered over two million square miles.
"This evidence was uncovered at the opposite end of the Roman Empire, at the furthest reaches of England.
"We are on the very northern part of the Roman Empire, on the border of the frontier of the Empire."
The series went on to reveal how Vindolanda tablets were uncovered. It added: "Around the early second century AD, the largest Roman army in the entire Empire was stationed here, on Hadrian's Wall, struggling to keep hold of its newly occupied territory.
Archaeologists working near Hadrian's Wall
"The British really didn't want to be conquered, so over 30,000 soldiers and their families and communities were stationed permanently in Roman Britain.
"For the past 13 years, Dr Andrew Birley has supervised investigations at Vindalanda Fort, one of 16 heavily defended garrisons that ran the length of Handrian's Wall.
"He's found evidence it was manned by soldiers from across the Empire."
Archaeologists then made a stunning find within the tablet collection. The series continued: "Among the meany treasures, archaeologists have uncovered around 500 letters sent to and from Roman troops based at the fort.
"Many contain requests for favourite foods from back home, the find reveals that, even here, soldiers were being sent a variety of goods from their home countries.
"Among the most sought after products was garum."
At the time of their discovery, the tablets were the oldest surviving handwritten documents in Britain.
More than 500 letters were uncovered
The letters are on display in the British History Museum
Written on fragments of thin, postcard-sized wooden pages with carbon-based ink, the tablets date to the 1st and 2nd centuries AD.
The documents record official military matters as well as personal messages to and from members of the garrison of Vindolanda, their families, and their slaves.
Highlights of the tablets include an invitation to a birthday party held in about 100AD, which is perhaps the oldest surviving document written in Latin by a woman.
The excavated tablets are nearly all held at the British Museum, but arrangements have been made for some to be displayed at Vindolanda.
« Archaeologists discovered "the ketchup of the Roman world" buried in Pompeii for almost 2,000 years
Roman-Era Structures Found Near Sphinx-Lined Egyptian Avenue »


text:
Taonura is een geslacht van sponsdieren uit de klasse van de Demospongiae (gewone sponzen).

Soorten
 Taonura byssoides (Lamarck, 1814)
 Taonura carteri (Lendenfeld, 1889)
 Taonura colus (Lamarck, 1814)
 Taonura crassior (Topsent, 1931)
 Taonura flabelliformis Carter, 1882
 Taonura haackei (Lendenfeld, 1889)
 Taonura marginalis (Lendenfeld, 1888)
 Taonura pala (Lamarck, 1814)
 Taonura palmatiformis (Hyatt, 1877)
 Taonura tuba (Lendenfeld, 1889)

Gewone sponzen

redpajama_set_name: RedPajamaWikipedia


text:
Six Missouri House special elections on the November ballot
By Jaclyn Beran
Candidates had until August 22 to file to run for four vacant seats in the Missouri House of Representatives. The special elections are scheduled for November 5. The following candidates filed to run:
District 22: The seat became vacant after Rep. Brandon Ellington (D) was elected to be an at-large District 3 member of the Kansas City City Council in June 2019. He ran unopposed in the 2018 election. Yolanda Young (D), Tammy Louise Herrera (R), and Jeff Francis (G) filed to run for the vacant seat.
District 36: Rep. DaRon McGee (D) resigned his seat in April 2019 to take another job. He won re-election in 2018 with 78.1% of the vote. Mark Sharp (D) and Bob Voorhees (G) filed to run for the vacant seat.
District 74: The seat became vacant after Rep. Cora Walker (D) resigned on July 29, to take a job as a policy director for St. Louis County Executive Sam Page. Mike Person (D) and Nick Kasoff (L) filed for the seat.
District 78: Rep. Bruce Franks (D) resigned his seat on July 31. Rasheen Aldridge (D) is running unopposed in the special election.
Special elections in District 99 and District 158 of the state House are also scheduled for November 5. The filing deadline for those two special elections passed in May. The following candidates filed to run:
District 99: Rep. Jean Evans (R) stepped down from the seat in February 2019 to become the executive director of the Missouri GOP. She won re-election in 2018 with 53% of the vote. Trish Gunby (D) and Lee Ann Pitman (R) filed to run for the vacant seat.
District 158: This seat became vacant after Rep. Scott Fitzpatrick (R) became the state treasurer of Missouri in January 2019. He ran unopposed in the 2018 election. Lisa Kalp (D) and Scott Cupps (R) filed to run for the vacant seat.
As of August, 73 state legislative special elections have been scheduled or held in 24 states. Between 2011 and 2018, an average of 77 special elections took place each year.
Heading into the election, Republicans have a 113-43 majority in the state House with seven vacancies. Missouri has a Republican state government trifecta. A trifecta exists when one political party simultaneously holds the governor's office and majorities in both state legislative chambers.
https://ballotpedia.org/State_legislative_special_elections,_2019
https://ballotpedia.org/Missouri_House_of_Representatives
Jaclyn Beran
Jackie Beran is a staff writer at Ballotpedia. Contact us at editor@ballotpedia.org.


text:
Сен-Реми́-су-Барбюи́з () — коммуна во Франции, находится в регионе Шампань — Арденны. Департамент — Об. Входит в состав кантона Арси-сюр-Об. Округ коммуны — Труа.

Код INSEE коммуны — 10361.

Коммуна расположена приблизительно в 140 км к востоку от Парижа, в 60 км южнее Шалон-ан-Шампани, в 21 км к северу от Труа.

Население
Население коммуны на 2008 год составляло 173 человека.

Экономика
В 2007 году среди 114 человек в трудоспособном возрасте (15—64 лет) 95 были экономически активными, 19 — неактивными (показатель активности — 83,3 %, в 1999 году было 78,1 %). Из 95 активных работали 87 человек (45 мужчин и 42 женщины), безработных было 8 (2 мужчины и 6 женщин). Среди 19 неактивных 5 человек были учениками или студентами, 8 — пенсионерами, 6 были неактивными по другим причинам.

Фотогалерея

Примечания

Ссылки

Коммуны департамента Об


text:
Last edited by Zulurr
Thursday, August 6, 2020 | History
3 edition of Annual ground-water use in the Twin Cities metropolitan area, Minnesota, 1970-79 found in the catalog.
Annual ground-water use in the Twin Cities metropolitan area, Minnesota, 1970-79
Published 1984 by U.S. Dept. of the Interior, Geological Survey in St. Paul, Minn .
Groundwater -- Minnesota.,
Water use -- Minnesota -- Minneapolis Metropolitan Area.,
Water use -- Minnesota -- Saint Paul Metropolitan Area.
Other titles Annual ground water use in the Twin Cities metropolitan area, Minnesota, 1970-79
Statement by M.A. Horn ; prepared in cooperation with the Metropolitan Council of the Twin Cities and the Minnesota Department of Natural Resources.
Series Open-file report / U.S. Geological Survey -- 84-577, U.S. Geological Survey open-file report -- 84-577.
Contributions Metropolitan Council of the Twin Cities Area., Minnesota. Dept. of Natural Resources., Geological Survey (U.S.)
Format Microform
Pagination 1 v.
Production of Annual GeneratiOIl Size of Reservoir foodgJains pet Yltar A. Large Dalllll Bhakra Dam India meters Million Ha ,MW Irrigation, Drinking Water fur several System 11 Concrete and 27 Million Tonnes 14 Bn kWh rural and urban areas in the command Earth-filled as well as also for Delhi Hydropower 18 BCM shared by at least. Climate change futures: health, ecological and economic dimensions.
Publishing platform for digital magazines, interactive publications and online catalogs. Convert documents to beautiful publications and share them worldwide. Title: Killing Our Own: The Disaster of America's Experience with Atomic Radiation, Author: calder john, Length: pages, Published: annual rate of million units, up more than 1 percent from February; current industry schedules indicate a seasonally adjusted annual rate of million units for April. Production of business equipment, which had reached a low in February , showed average monthly increases of about percent through January
KOO - Free ebook download as PDF File .pdf), Text File .txt) or read book online for free.
Abraham Lincoln, Lincoln and Wilson, Woodrow Wilson
emergent Irish state
Nineteenth century British glass
Kindle my heart
Plus TC & D
Buffalo Medical and Surgical Journal
Growing up sew liberated
Researches as to the identity of the periodic comet of 1889-1903 (Brooks)
Sculpture of Cyprus
Wildflowers of the Santa Barbara Foothills
U.S. Census Monitoring Board
Strange trafficking and curious merchandise
Ecclesiastical history.
Partners in freedom
Journal of an itinerant artist
Nursing Educators Microworld Cai Resource Book, 1990
Annual ground-water use in the Twin Cities metropolitan area, Minnesota, 1970-79 Download PDF EPUB FB2
Annual ground-water use in the Twin Cities metropolitan area, Minnesota, (Open-file report / U.S. Geological Survey) [M. A Horn] on *FREE* shipping on.
Buy Annual ground-water use in the Twin Cities metropolitan area, Minnesota, Annual ground-water use in the Twin Cities metropolitan area report / U.S.
Geological Survey) by Horn, M. A (ISBN:) from Amazon's Book Store. Everyday low prices and free delivery on eligible : M. A Horn. Get this from a library. Annual ground-water use in the Twin Cities metropolitan area, Minnesota, [M A Horn; Metropolitan Council of the Twin Cities Area.; Minnesota.
Department of Natural Resources.; Geological Survey (U.S.)]. Minutes by Metropolitan Council of the Twin Cities Area Annual ground-water use in the Twin Cities metropolitan area, Minnesota, by M. Conversion of the Twin Cities metropolitan area numerical ground-water-flow model from the Trescott-Larson computer code to the McDonald-Harbaugh computer code by Richard J Lindgren.
Minneapolis: University of Minnesota Press. MLA Citation. Harrigan, John J. and Johnson, William C. Governing the Twin Cities region: the Metropolitan Council in comparative perspective / by John J.
Harrigan and William C. Johnson University of Minnesota Press Minneapolis Australian/Harvard Citation. Due to the need to contain the spread of coronavirus (COVID) the Library building and reading rooms are closed to visitors until further notice.
Andrews, W.J., Trotta, L.C., and Schoenberg, M.E.,Ground-water withdrawals and water-level declines from in the Prairie du Chien-Jordan and Mt.
Simon-Hinckley aquifers, Twin Cities Metropolitan Area, Minnesota, in Proceedings of the 31st Annual Conference of the American Water Resources Association, November, Houston. Metropolitan Museum. Top NASA Images Solar System Collection Ames Research Center. Brooklyn Museum.
Full text of "Monthly catalog of United States government publications". The International Symposium on Radon and Radon Reduction Technology "Assessing the Risk" SeptemberSheraton Park Place Hotel Minneapolis, Minnesota Sponsored by: U.S. Environmental Protection Agency Air and Energy Engineering Research Laboratory and U.
Environmental Protection Agency Office of Radiation Programs and Conference of. Metropolitan Museum.
Top NASA Images Solar System Collection Ames Research Center. Brooklyn Museum. Full text of "Agriculture fact book" See other formats. Further aggregations of geographic areas provided city totals. Study Area The Study area includes 83 cities located in 60 metropolitan statistical areas in the Midwest.
These cities represent the central cities in all of the metropolitan statistical areas in the States of Illinois, Indiana, Minnesota, Wisconsin, Michigan, and Ohio. Agriculture -- France. See also what's at your library, or elsewhere.
Broader terms: Agriculture; Agriculture -- Europe; France; Narrower terms: Agriculture -- France -- Early wor. Sustainability: A Comprehensive FoundationRice University, Houston, Texas. > > > > > > charles alexander / chax press fold the book inside the book keep it open always read from the inside out speak then=20 ===== Date: Sat, 2 Dec Reply-To: UB Poetics discussion group Sender: UB Poetics discussion group From: Stephen Vincent Subject: Re: Re:urgent query on Stein In-Reply-To: These patterns were copied by others and often acquired custom status and.
places) that were known with certainty to the land use decision maker, but. Land Resource Management: Economic Foundations and New Directions Raleigh Barlowe, Soji Adelaja, and Paul Babladelis Michigan State University. Metropolitan Museum. Top NASA Images Solar System Collection Ames Research Center.
Brooklyn Museum. Full text of "FWS/0BS" See other formats. Deadliest American Disasters and Large-Loss-of-Life Events. (10 or more lives lost with notable exceptions) Home; About Project; Chronology & Typology Docs; State & Mortality Docs.
- Free download as PDF File .pdf), Text File .txt) or view presentation slides online. Configuration of water table and distribution of downward leakage to the Prairie du Chien-Jordan Aquifer in the Minneapolis-Saint Paul metropolitan area, Minnesota.
USGS Publicati. 78 FR - Dakota, Minnesota & Eastern Railroad Corporation-Abandonment Exemption-in Scott County, Iowa. Federal Register. afterward, Gary Shannon and Alan Dever () wrote the widely read book that first introduced a generation of graduate students in geography to the subject: Health Care Delivery.
Settlement forms, systems of cities (urban hierarchy), transportation networks, and population mobility had become objects of modeling in urban geography.Agriculture Fact Book U.S. Department of Agriculture Office of Communications The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, and marital or family status.They did most of the dying."[4] A U.S.
military inspection team was dispatched for the nuclear- ravaged cities, reaching Hiroshima on September 8 and going on to Nagasaki a few days later.
"In all the areas examined, ground contamination with radioactive materials was found to be below the hazardous limits," the U.S. Army's official history.
axendadeportiva.com - Annual ground-water use in the Twin Cities metropolitan area, Minnesota, 1970-79 book © 2020


text:
Mercedes-AMG C63 S review
By Glenn Butler, 24 Feb 2015 Reviews
The latest Mercedes-AMG C63 S is a major update for Benz's most popular performance sedan and wagon. And it's bloody good
THE latest Mercedes-AMG C63 S is a major update for Benz's most popular performance sedan and wagon. It's based on the C-Class launched in 2014 and gets a new, more powerful and more economical engine, a raft of dynamic upgrades and a suite of S-Class safety features. And it's bloody good.
The Mercedes-AMG C63 S is a high-performance compact luxury sports sedan and wagon. A coupe will follow in 2016. The C63 S combines elements popular with Australians – rear-wheel drive, brawny V8 engine – with lashing of German luxury and prestige to be the archetypal slugger in a Saville Row suit.
WHY WE'RE TESTING IT
Despite the badge carrying over, this is a new-generation model that abandons the venerable and enthusiastic 6.3-litre V8 for the AMG GT's new 4.0-litre twin-turbocharged V8. Unlike the previous generation, which was offered in C63 and C63 S trim (the latter with extra power and performance), this time around Australia's getting the full-fruit S model only. Wheels flew to Portugal to be among the first publications in the world to test Benz's new BMW M3 rival.
Audi RS4, BMW M3, Jaguar XFR
The Mercedes-AMG C63 S may have farewelled one of AMG's great engines, but its replacement is a corker that absolutely overcomes our misgivings about turbo-immersion and driver involvement. Not to mention the 1995-era price!
PLUS: Straight-line performance; drivetrain response; handling; sound
MINUS: Reactive ride; tyre noise
PROGRESS is a bitch, because it sometimes kills the good things in life. Mix tapes. Love letters. Idle moments. Sunday roasts. The free-breathing V8 engine.
With the new-generation Mercedes-AMG C63 sedan and wagon launched internationally this month, AMG's brilliant 6.2-litre naturally-aspirated V8 engine is all but gone. Only one model survives, and that's the low-volume C63 Coupe, which is on death row ahead of an all-new and turbocharged model later this year.
The C-Class-based C63 sedan and wagon are the first mainstream Benz models to get the mighty new 4.0-litre twin-turbocharged V8 from the recently launched AMG GT super-coupe. And in full GT 375kW/700Nm tune, too, in the case of the potent C63 S, which is the only model Australia will get. The only difference is that the more extreme GT runs a dry-sump configuration.
Another tech transfer from the AMG GT are dynamic engine mounts, which AMG claims soften to reduce vibration during light driving and stiffen to improve vehicle dynamics during sporty driving.
Straight-line performance is the most obvious beneficiary of AMG's engine largesse. The new C63 S accelerates from standstill like no C-Class AMG before it.
Typical of modern turbo engines, the M177 V8 generates peak torque across a wide rev band, in this case from 1750 to 4400rpm. This manifests as always-ready acceleration, regardless of the selected gear or vehicle speed. It certainly helps if the driver primes the engine with a gear that lands it in the 4000-5000rpm sweet spot, because that's where the C feels the most relentless. But at anything from 2000rpm, the C63 surges with a vitality beyond the old 6.2-litre V8.
It's louder, too, and not with the hairdryer whoosh often found with twin-turbo applications. Mounting the turbos inside the V instead of below the cylinder banks helps this engine's gravelly V8 notes aurally dominate those hurricane forces, resulting in a fantastic and energetic soundtrack. It comes complete with an orchestrated 21-gun salute for every full-throttle gearchange, and AMG's customary burble and gurgle on overrun and downchange. It feels contrived, but it adds to the enjoyment of a spirited drive. And that's the point.
Visually, the new C63 is understated despite a road-eating front spoiler and black alloys. The rear looks more muscular with its quad tailpipes and bootlid lip-spoiler. Overall, though, the exterior is a reflection of the C63's duality. Yes, it is bought because of the way it pulverises the tarmac, but most times it's gliding through peak-hour traffic.
It straddles those opposing worlds as well as can be expected. The suspension has some bump-soaking abilities, but this is a sports sedan and body control is paramount, so the ride is firm and at times reactive to surface changes. The steering is light and easy, yet offers decent feel for the road and feedback on front-end load.
But for me the C63's best asset is the one I expected to like the least before driving it: the engine. This new twin-turbo V8 is a monster, no question, yet it's a refined and responsive beast that reacts precisely to throttle inputs, and that helps the driver get the most out of rear-end traction. It's easy to obliterate the tyres' grip on the tarmac with an exuberant push on the throttle, but it's also surprisingly easy to feel when the rear is reaching its limits, and hold it there.
This is a twin-turbocharged application that very closely mimics the best characteristics of its naturally aspirated predecessor, while outperforming it in performance and efficiency. It's a thoroughly engaging performance sedan to drive, and its respect for the driver is paramount. Hard not to like that.
In fact, there's very little not to like with the new C63 S, not even the price. At $154,900, it's exactly what this car's distant ancestor the C36 cost 20 years ago. That's commendable, given the huge advances the C63 makes over its immediate predecessor, let alone the 1995 C36. Maybe progress has some redeeming qualities after all.
Model: Mercedes-AMG C63 S
Engine: 3982cc V8 (90°), dohc, 32v, twin turbo
Max power: 375kW @ 5500rpm
Max torque: 700Nm @ 1750-4500rpm
Transmission: 7-speed dual-clutch automatic
0-100km/h: 4.0sec (claimed)
Economy: 8.6L/100km
On sale: July
Mercedes-AMG C63 Black Series unleashed on the Isle of Man TT
By Glenn Butler | 13 Jul 2020
No speed limits, the most dangerous roads in motorsport, and AMG's bonkers C63 Black Series. This is about to get wild.
Teenager caught at 308km/h in Mercedes-AMG C63
By Simon Telford | 14 May 2020
Canadian police stunned as an 18-year-old records triple the legal speed limit
Behold some of the coolest fast wagon you could ever own
By MOTOR Staff | 26 Mar 2020
These spacious super-haulers are guaranteed to make the dog throw up
How the Black Series became a badge to be feared
By Cameron Kirby | 14 Jul 2020
When is an AMG more than an AMG? When it has a Black badge slapped on the rear. Hold on tight…
Jaguar XE pre-production prototype drive
2015 Mercedes-AMG GT review
First Drive: BMW M3 & M4