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https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUuc3RhZ2luZy5tZWRzY2FwZS5jb20vYXJ0aWNsZS8yMDg1NDMxLW92ZXJ2aWV3
Factor-Inhibitor Assay
Author: Bishnu Prasad Devkota, MD, MHI, FRCS(Edin), FRCS(Glasg), FACP, FAMIA; Chief Editor: Eric B Staros, MD more...
Sections Factor-Inhibitor Assay
If, after an adequate infusion of factors VII, VIII, IX, XI, and V, bleeding continues, a factor-inhibitor assay is indicated. Although nearly all procoagulants have an inhibitor, the inhibitor to factor VIII is the most common.
Under normal circumstances, no factor inhibitors are present.
Factor inhibitors are reported in Bethesda units (BU).
Factor VIII inhibitors, which are immunoglobulin G (IgG) antibodies against factor VIII, occur in hemophilia A as alloantibodies. As autoantibodies, they usually arise spontaneously, particularly in the elderly population, but they are also found in pregnancy and autoimmune disease.
Collection details areas follows:
Specimen: Blood (0.5 mL frozen plasma X4 or two 3.2% sodium citrated tubes, 5 mL each)
Container: Blue-top vacuum tube
Collection method: Routine venipuncture
To comply with Occupational Safety and Health Administration (OSHA) safety standards, all samples must be sent in a sealed, leak-proof container with a biohazard sticker attached.
An inhibitor exists for nearly every procoagulant, with the inhibitor to factor VIII being the most common. Detection of factor VIII inhibitor is accomplished by mixing the test plasma with a known amount of factor VIII. Following a 2-hour incubation period at 37°C, a factor VIII assay is used to determine residual factor VIII activity. The presence or absence of a factor VIII inhibitor can be determined through comparison of the difference in factor VIII activity between the incubation mixture and a control mixture. The partial thromboplastin time (PTT) is prolonged by some antibodies only after incubation. [1]
Among the many protease inhibitors in plasma, tissue factor pathway inhibitor (TFPI) and antithrombin are the ones that are most specifically involved in inhibition of coagulation factors. Another potentially important regulator of the coagulation system, the protein Z/protein Z–dependent protease inhibitor (ZPI) system, is also emerging. [2]
Tissue factor pathway inhibitor
Depending on the degree of proteolysis of the carboxy-terminal region, TFPI, a single-chain polypeptide, has an Mr of 34,000-40,000. Unlike other coagulation protease inhibitors, TFPI has inhibitory sites for factor Xa and for the factor VIIa/tissue factor (TF) complex, and it cannot inhibit the factor VIIa/TF complex without being bound to factor Xa. [2, 3]
Endothelial cells are the primary site of plasma TFPI synthesis. [4] Most circulating TFPI is bound to lipoproteins, but on the surface of endothelial cells, a second pool of TFPI is bound to heparan sulfates. When heparin is administered, the endothelial cell–bound TFPI is released and the plasma level rises severalfold. [5]
TFPI exists in the plasma at only about 2.5 nM, while antithrombin occurs at about 2 µmol. However, TFPI and antithrombin have a similar rate of reaction with factor Xa in plasma. Therefore, TFPI makes a significant contribution to factor Xa inhibition in vivo. [6] The human TFPI gene is found on chromosome 2.
Antithrombin
A deficiency of antithrombin increases the risk of thrombosis, revealing its importance as a functional inhibitor of the blood coagulation proteases. Thrombin, factor Xa, and factor IXa are the primary proteases that antithrombin targets, [7, 8] with heparin increasing its inhibition of coagulation factors. Unless it is complexed to TF in the presence of heparin or cell surface glycosaminoglycans, factor VIIa resists being inhibited by antithrombin. [6]
The protease-serpin complex is cleared from the circulation by receptor-mediated endocytosis in the liver. [9] The antithrombin gene is found on the long arm of chromosome 1.
Protein Z/protein Z–dependent protease inhibitor
Coagulation factors XIa and Xa are inhibited by ZPI, an Mr 72,000 serine protease inhibitor. The presence of protein Z, a vitamin K–dependent plasma protein, increases its inhibition of factor Xa over 1000-fold. [10] Protein Z/ZPI's physiologic activity in the coagulation system is unclear.
In a mouse model, protein Z deficiency does not cause thrombosis, but it does significantly increase the thrombotic tendency of mice who simultaneously express the factor V Leiden genotype, a known thrombotic risk factor. [11]
The protein Z gene exists on the long arm of chromosome 13, where it lies in close proximity to the genes for factor X and factor VII. [12]
Factor VIII inhibitors
Factor VIII inhibitors are the inhibitors that occur most commonly in the factor inhibitor assay. Although they are found most often in individuals with hemophilia who are receiving factor replacement, they can also occur in patients with autoimmune diseases and lymphoma and in pregnant (postpartal) or elderly patients.
Factor VIII inhibitors are measured in BU; highly potent inhibitors have levels of more than 10 BU.
A study by Chen et al of three global hemostatic assays—thromboelastography, Innovance ETP (endogenous thrombin potential), and Thrombinoscope—suggested that Thrombinoscope with platelet-poor plasma (PPP) reagent is sensitive enough to factor VIII inhibitors to monitor patients who have hemophilia with inhibitors. The assay, through assessment of thrombin-generation potential, demonstrated a dose-dependent response to different factor VIII–inhibitor concentrations. [13]
A study by Bachelet et al indicated that in replacement therapy for severe hemophilia A, the risk of developing factor VIII inhibitors is greater in patients who are HLA-DRB1*15 positive, with genotype G/A or A/A for IL10 rs1800896. In contrast, the investigators reported that the risk is low in patients who are HLA-DRB1*15/HLA-DQB1*02 negative, with genotype T/T or G/T for CD86 rs2681401. [14]
The Survey of Inhibitors in Plasma-Product Exposed Toddlers (SIPPET) study indicated that in children with severe hemophilia A who have previously undergone minimal or no treatment, those who receive therapy with recombinant factor VIII products have twice the chance of developing inhibitors as do those treated with plasma-derived factor VIII, during the first 50 exposure days. A survey by Sande et al of hemophilia providers suggested that the SIPPET results have influenced the choice of factor VIII therapy being used in the United States, with employment of the recombinant agent for patients with minimal or no previous treatment decreasing from 70.5% to 27.8% of the clinicians and utilization of plasma-derived factor VIII rising from 8.2% to 16.7% of the providers. [15, 16, 17]
In order to predict the response of a patient with hemophilia to factor replacement therapy, factor VIII inhibitor should be measured before the patient undergoes any significant invasive procedure. It is important to confirm the patient's response to factor administration before the procedure is begun.
In the short-term, the inhibitors for low titers may be overridden by infusion of factor VIII concentrate, although in some patients, such infusion may increase the inhibitor titer. Infusion of prothrombin complex concentrate (PCC), activated PCC, porcine factor VIII concentrates, and VIIa have been found to be useful for high-titer inhibitors. [18, 19, 20] To manage inhibitors, it is efficacious to use combined immunosuppressant programs that include steroids, cytotoxic agents, plasma processing over columns that remove IgG and IgG-containing immune complexes, [21] and high-dose intravenous immunoglobulin.
The recombinant monoclonal antibodies of emicizumab, a nonfactor agent for persons with hemophilia A, simultaneously bind to factors IXa and X. Consequently, factor VIIIa does not need to play a role in factor X activation, which means that coagulation is not hindered by factor VIII inhibitors. [22]
Rituximab therapy, while effective in patients with high titers of acquired factor VIII, may not produce a sustained response on its own. It may therefore be better to combine rituximab with other therapies in high-risk individuals. [23, 24, 25, 26]
In persons without hemophilia, inhibitors are more responsive to simple immunosuppressive agents such as prednisone and azathioprine. However, inhibitors must be controlled in such patients to avoid an increase in the risk of bleeding. Owing to the high risk of hemorrhage, an emphasis has been placed on meticulous perioperative hemostatic correction. Following major surgery, it is necessary to maintain the correction for at least 10 days to prevent delayed hemorrhage. [18]
Thrombosis (hypercoagulable state), rather than bleeding, is caused by lupus anticoagulant (phospholipid inhibitor), despite the fact that it is usually associated with a prolonged PTT. This inhibitor may, however, cause bleeding diathesis in very rare cases; such a case may be indicated by prolongation of the prothrombin time (PT) in addition to the PTT. [18]
Laboratory results typically consist of a prolonged PTT and/or Russell viper venom time (RVVT) with evidence of an inhibitor and interference on several of the coagulation factor assays. Characteristically, via the tissue thromboplastin inhibition [TTI] test, an abnormally steep rise in the PT with serial dilution of thromboplastin in vitro is found.
This test should be carried out prior to anticoagulation, since heparin and warfarin anticoagulation may demonstrate similar phenomena. By removing the inhibitor, absorption of the patient's plasma with platelet phospholipid in vitro may normalize the PTT, TTI, and RVVT test results.
Clinically important hypercoagulability exists in approximately 25% of patients with lupus anticoagulants. To reduce the risk of venous thromboembolism, perioperative prophylactic heparin is recommended. Because PT in these patients is unpredictable, the degree of warfarin effect may be more reliably monitored using chromogenic factor X levels. The risk of arterial thrombosis is also greater in these patients.
Factor V inhibitors
An inhibitor to factor V (a contaminant of the bovine product) may develop in some individuals who have been exposed to surgical sealant containing topical bovine thrombin. In rare cases, cross-reactivity may cause a significant reduction in human factor V levels. Although these antibodies eventually disappear in weeks, patients with significant bleeding may require treatment with plasma and platelets.
Indication/Applications
Continuing bleeding after adequate infusion of VII, VIII, IX, XI, and V is an indication for the use of the factor-inhibitor assay.
If a prolonged PT or aPTT performed on a 1:1 mixture of the patient's plasma and normal plasma leads to suspicion that an inhibitor is present, additional studies can help to determine the inhibitor's nature and titer.
Among immediate-type inhibitors, that is, those that do not require incubation, the existence of heparin in the sample may be the most common cause. This cause can be verified by finding a prolonged thrombin time on a test of the patient's plasma that is corrected with toluidine blue or other agents that neutralize heparin.
Several methods are available for the detection of the lupus anticoagulant, which also requires no incubation. However, lupus anticoagulant is usually associated with a PT that is less prolonged than the aPTT. Moreover, depending on how much phosphatidyl serine exists in each reagent, aPTT reagents differ markedly in their sensitivity to lupus-type anticoagulant. [18]
The development of immunoglobulin inhibitors to specific coagulation factors may occur either (1) after patients with inherited coagulation factor deficiencies have undergone factor replacement therapy or (2) spontaneously in patients with no factor deficiencies. By incubating the patient's plasma with normal plasma, usually for 2 hours at 37°C (98.6°F), and then assaying the specific factor, it is frequently possible to detect antibodies that neutralize factor activity. Although originally designed to quantify factor VIII inhibitors, the Bethesda assay can be modified to detect other coagulation factor inhibitors. [27]
Rather than directly neutralizing clotting activity, some inhibitors instead form complexes with coagulation factors as a means of reducing factor levels, with the complexes rapidly being cleared from the circulation. Such plasmas may be confused with inherited deficiency states because they do not produce prolonged clotting times when mixed 1:1 with normal plasma. Identification of this type of inhibitor requires more elaborate assays; such inhibitors may, for example, cause severe prothrombin deficiency in some patients with antiphospholipid syndrome and deficiency of von Willebrand factor in patients with some acquired forms of von Willebrand disease. [28]
Coagulation factor inhibitors may lead to potentially fatal situations, particularly in patients who are otherwise critically ill. The inhibitor's potency can be measured by titrating the effect of plasma dilutions on the result of mixing the patient's plasma with pooled normal plasma.
Among coagulation factor inhibitors, those directed against factor VIII are the most commonly found. Lupus anticoagulant has been encountered not only in patients with systemic lupus erythematosus (SLE) and drug-induced SLE syndromes, but also in patients with other autoimmune diseases, as well as in otherwise normal persons. A spontaneous reduction in lupus anticoagulants may occur after an offending drug, such as procainamide or a phenothiazine, is discontinued, or may result from the use of immunosuppressive agents such as prednisone.
What is the reference range for a factor inhibitor assay?
How are factor inhibitors measured?
What conditions cause factor inhibitors to occur?
How are specimens collected for a factor inhibitor assay?
What are factor inhibitors?
What is a tissue factor pathway inhibitor?
What is antithrombin?
What is a protein Z/protein Z–dependent protease inhibitor?
What are factor VIII inhibitors?
What are lupus anticoagulants?
What are factor V inhibitors?
When are factor-inhibitor assays indicated?
What should be considered when performing a factor-inhibitor assay?
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Peyvandi F, Cannavo A, Garagiola I, et al. Timing and severity of inhibitor development in recombinant versus plasma-derived factor VIII concentrates: a SIPPET analysis. J Thromb Haemost. 2018 Jan. 16 (1):39-43. [QxMD MEDLINE Link]. [Full Text].
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Sande CM, Al-Huniti A, Ten Eyck P, Sharathkumar AA. Impact of the Survey of Inhibitors in Plasma-Product Exposed Toddlers (SIPPET) study and its post hoc analyses on clinical practice in the United States: A survey of Haemophilia and Thrombosis Research Society members. Haemophilia. 2019 Jul 2. [QxMD MEDLINE Link].
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Nilsson IM, Jonsson S, Sundqvist SB, Ahlberg A, Bergentz SE. A procedure for removing high titer antibodies by extracorporeal protein-A-sepharose adsorption in hemophilia: substitution therapy and surgery in a patient with hemophilia B and antibodies. Blood. 1981 Jul. 58(1):38-44. [QxMD MEDLINE Link].
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Field JJ, Fenske TS, Blinder MA. Rituximab for the treatment of patients with very high-titre acquired factor VIII inhibitors refractory to conventional chemotherapy. Haemophilia. 2007 Jan. 13(1):46-50. [QxMD MEDLINE Link].
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Kasper CK, Aledort L, Aronson D, Counts R, Edson JR, van Eys J. Proceedings: A more uniform measurement of factor VIII inhibitors. Thromb Diath Haemorrh. 1975 Nov 15. 34(2):612. [QxMD MEDLINE Link].
Inbal A, Bank I, Zivelin A, Varon D, Dardik R, Shapiro R. Acquired von Willebrand disease in a patient with angiodysplasia resulting from immune-mediated clearance of von Willebrand factor. Br J Haematol. 1997 Jan. 96(1):179-82. [QxMD MEDLINE Link].
Bishnu Prasad Devkota, MD, MHI, FRCS(Edin), FRCS(Glasg), FACP, FAMIA Adjunct Professor of Medicine, St Louis University School of Medicine; Chief Health Informatics Officer, VISN 17, VA Heart of Texas Healthcare Network
Bishnu Prasad Devkota, MD, MHI, FRCS(Edin), FRCS(Glasg), FACP, FAMIA is a member of the following medical societies: American College of Physicians, American Medical Informatics Association, Healthcare Information and Management Systems Society, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh
George Ansstas, MD Assistant Professor of Medicine, Division of Medical Oncology, Washington University School of Medicine
George Ansstas, MD is a member of the following medical societies: American Medical Association
encoded search term (Factor-Inhibitor Assay) and Factor-Inhibitor Assay

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text:
A Caraval Novel
Caraval (Volume 2)
Author: Stephanie Garber
Buzzfeed Best Books of the Year
Read Excerpt
Tella was no longer floating.
She was on the damp ground, feeling far, far away from the bright, sparkly thing she'd been the evening before. Back when Legend's private isle had radiated amber-tipped light, which breathed enchantment and wonder, along with a hint of deception. A delectable combination. And Tella had reveled in it. During the party to celebrate the end of Caraval, she had danced until her slippers were stained with grass and sipped flutes of bubbly wine until she'd practically floated.
But now she was facedown on the cold, hard forest floor.
Not daring to open her eyes, she groaned and brushed bits of nature from her hair, wishing some of the other remnants from last night could be as easily swept away. Everything reeked of stale liquor, pine needles, and mistakes. Her skin itched and crawled, and the only thing worse than the spinning in her head was the twisted soreness in her back and neck. Why had she thought falling asleep outside was a brilliant idea?
"Argh." Someone grunted the not-quite-satisfied sound of a person on the verge of waking up.
Tella opened her eyes, peered to the side, and then closed her lids immediately. Dirty saints.
She was not alone.
Amid the towering trees and the untamed greens of the forest floor, Tella had flashed open her eyes just long enough to glimpse a dark head of hair, bronzed skin, a scarred wrist, and a boy's hand covered with a black rose tattoo. Dante.
It all rushed back in a surge of blurry memories. The feeling of Dante's experienced hands wrapped around her hips. His kisses on her neck, her jaw, then her mouth as their lips became intimately acquainted.
What in all the hells had she been thinking?
Of course, Tella knew exactly what her thoughts had been during the Caraval performers' party the night before. The world had tasted like magic and starshine, like granted wishes and dreams come true, yet beneath it all, death still coated Tella's tongue. No matter how much champagne she drank, or how warm the air grew from dancing, Tella still shivered from the chilling recollection of how it had felt to die.
Her jump from Legend's balcony had not been an act of despair; it had been a leap of faith. But for just one night she hadn't wanted to think about it, or why it mattered. She wanted to celebrate her success, to forget everything else. And Dante had looked like the perfect way to do both. He was attractive, he could be charming, and it had been too long since she had been properly kissed. And, saints, did Dante know how to kiss.
With another groan, he stretched beside her. His large hand landed on her lower back, warm and firm, and far more tempting than it should have been.
Tella told herself she needed to escape before he woke. But even asleep, Dante was so good with his hands. He idly ran his fingers up her spine to her neck, lazily digging into her hair just enough to make her back arch.
His fingers stilled.
Dante's breathing grew suddenly quiet in a way that told Tella he was now awake as well.
Swallowing a curse, she hastily pushed up from the ground, away from his stilled, skilled fingers. She didn't care if he saw her sneaking off; it would be far less uncomfortable than exchanging any forced pleasantries before one of them became bold enough to make an excuse for why he or she needed to rush away. Tella had kissed enough young men to know that anything said by a boy right before or directly after she kissed him could not be believed at all. And she really needed to leave.
Tella's memories might have been blurry, yet somehow she couldn't manage to forget the letter she'd received before things became interesting with Dante. A stranger, face hidden underneath the cloak of night, had slid the note into her pocket and disappeared before she could follow. She wanted to reread the message right away, but considering what she owed the friend who'd sent it, she did not think that would be very wise. She needed to return to her room.
Damp earth and spiked tree needles snuck between her toes as she began to slink away. She must have lost her slippers somewhere, but she didn't want to waste time searching for them. The forest was tinged with indolent honey light and punctuated by heavy snores and murmurs that made Tella think she and Dante weren't the only ones who'd passed out under the stars. She didn't care if any of them saw her sneaking away from the pretty boy, but she didn't want anyone telling her sister.
Dante had been more than a little nasty to Scarlett during Caraval. He worked for Legend, so it had only been an act—but although Caraval was over, it was still somewhat difficult to weed out the bits of fact from fiction. And Tella didn't want her sister further hurt because Tella had chosen to have some fun with a boy who'd been so cruel to Scarlett during the game.
Thankfully the world remained asleep as Tella reached the edge of the forest, and then, Legend's turreted house.
Even now, with Caraval officially ended, and all the candles and lanterns inside unlit, the mansion still breathed wisps of beguiling ember-glow light, reminding Tella of tricks yet to be played.
Until yesterday, this estate had contained the entire world of Caraval. Its grand wooden doors had led visitors to elegant balconies draped with lush red curtains, which surrounded a city made of canals, streets that had minds of their owns, and uncanny shops full of magical pleasures. But in the brief time since the game had ended, the turreted house had shrunk in size and the ephemeral wonderland hidden within its walls had disappeared, leaving behind only the parts that would normally belong inside of a grand house.
Tella trotted up the closest staircase. Her room was on the second floor. With a rounded robin's-egg-blue door, it was easy to find. It was also impossible to miss Scarlett and Julian, standing next to it, holding on to each other as if they'd forgotten how to say the word good-bye.
Tella was glad her sister had finally lost herself in some happiness. Scarlett deserved every joy in the Empire, and Tella hoped it would last. She'd heard Julian didn't have a reputation for stringing girls along, he never carried on relationships after Caraval, and he'd not even been scripted to stay with Scarlett after bringing her to Legend's isle. But he lied for a living, which made it difficult for Tella to trust him. Yet, as the pair stood there with their arms wrapped around each other, and their heads leaning closer together, they looked like two halves of the same heart.
Their eyes stayed locked as Tella crept around them toward her room.
"Is that a yes?" Julian murmured.
"I need to talk to my sister," Scarlett said.
Tella halted in front of the door. She swore the letter in her pocket grew suddenly heavy, as if impatient to be read again. But if Julian had just asked Scarlett what Tella had hoped, then Tella needed to be a part of this conversation.
"What is it you want to talk to me about?" Tella interrupted.
Scarlett pulled back from Julian, but his hands remained wrapped around her waist, weaving through the blushing ribbons of her dress, clearly not ready to let her go. "I asked your sister if you'll both go with us to Valenda for Empress Elantine's seventy-fifth birthday celebration. There will be another Caraval and I have two tickets." Julian winked.
Tella tossed her sister a grin. This was exactly what she'd hoped for. Although a part of her still couldn't believe the rumors she'd heard over the past week were true. Caraval only occurred once a year, and she'd never known of two games being played so close together. But Tella supposed even Legend made exceptions for the empress.
Tella continued to look at her sister hopefully. "I'm surprised this is even a question!"
"I thought you didn't like Elantine's Day because it always overshadowed your birthday."
Tella wobbled her head as she weighed her answer. Her true reasons for wanting to go had little to do with Elantine's Day, although her sister was correct. For as long as Elantine had been empress of the Meridian Empire, her birthday had been a holiday, Elantine's Day, which was ushered in with a full week of parties and dances, bended rules, and broken laws. On the girls' home isle of Trisda, this holiday was only celebrated for one day, on the thirty-sixth day of the Growing Season, but it still overshadowed Tella's birthday, which had the misfortune of occurring the day afterward.
"It will be worth it to visit Valenda," Tella said. "When do we leave?"
"Three days," Julian answered.
Scarlett puckered her mouth. "Tella, we need to discuss this first."
"I thought you've always wanted to go to the capital, to see all its ancient ruins and the carriages that float through the sky, and this will be the party of the century! What's there to talk about?"
"The count."
Julian's brown skin went gray.
Tella's face might have done the same.
"The count lives in Valenda, and we can't let him see you," Scarlett said.
Scarlett was the overly cautious sister, but Tella couldn't blame her for this reservation.
Count Nicolas d'Arcy was Scarlett's former fiancé whom Scarlett's father had arranged for her to marry. Before Caraval, Scarlett had only written him letters, but she'd believed herself in love with him. She'd also thought the count would keep both her and Tella safe—until Scarlett met him during Caraval and learned what a despicable human being he was.
Scarlett was right to worry about the count. If Scarlett's former fiancé discovered Tella was alive, he could send word to their father—who believed Tella was dead—and it would shatter everything.
But things would also fall apart if Tella didn't go with Legend and his performers to the Empire's capital city of Valenda. She might not have had the chance to reread the letter from her friend, but she knew what he wanted, and she would never get it for him if she was separated from Legend and his performers.
During Caraval, Tella hadn't been entirely certain who worked for Legend. But all of his performers would be on the boat to Valenda—Legend might even be on the boat as well, giving her the opportunity she needed to finally get the one thing her friend required.
"The count is so concerned with himself he probably wouldn't recognize me even if I walked up to him and gave him a slap in the face," Tella said. "We only met for a moment, and I was not looking my best."
"Tella—"
"I know, I know, you want me to be serious," Tella cut in. "I'm not trying to mock you. I'm fully aware of the danger, but I don't think we need to be afraid of it. We could just as easily perish in a shipwreck, but if we let that fear stop us, we'll never leave this isle again."
Scarlett grimaced and turned to Julian. "Would you mind giving my sister and me a moment alone?"
Julian answered against Scarlett's ear, too low for Tella to hear. Whatever he said made Scarlett blush. Then he left and Scarlett's mouth flattened into a line as she and Tella enclosed themselves in Tella's room.
Inside, unmentionables were everywhere. Stockings peeked out from the drawers of a dresser topped off with bonnets, while a variety of capes, gowns, and petticoats formed a path to her bed, which was covered in a teetering pile of furs that she'd won in a card game.
Tella knew Scarlett thought she was lazy. But Tella had a theory: Neat rooms were easy to rifle through and search undetected because it was simple to put carefully placed things exactly where they'd been. But messes, on the other hand, were difficult to re-create. With one sweeping gaze, Tella could see no one had been brave enough to lay a finger on her personal disaster. Everything appeared untouched, even though there now seemed to be an additional bed, which Tella imagined must have magically appeared, or more likely had been carried upstairs for her sister.
Tella didn't know how long they'd be allowed to stay on the isle. She was relieved they weren't being kicked out right away, although if they'd been evicted, maybe Scarlett would have been more eager to travel to Valenda. But Tella didn't actually want her sister to be forced into anything; she hoped Scarlett would make the choice for herself. Though Tella could understand her sister's reluctance. Tella had died during the last game. But that had been her decision, it was for a good reason, and she wasn't planning on dying again. It had been as horrid for Tella as it had been for Scarlett. And there were still so many things Tella wanted—and needed—to do.
"Scar, I know you think I wasn't being serious out there, but I think we need to start being happy rather than serious. I'm not saying we need to participate in Caraval, but I think we should at least go to Valenda with Julian and the others. What's the point of all this glorious freedom if we don't enjoy it? Our father wins if we keep living as if we're still trapped beneath his heavy fists."
"You're right."
Tella must have misheard. "Did you say I'm right?"
Scarlett nodded. "I'm done with being scared all the time." She still sounded nervous, but her chin now lifted with something like determination. "I'd rather not play the game again, but I want to go with Julian to Valenda. I don't want to trap myself here like our father trapped us on Trisda."
Tella felt a surge of pride. Back on Trisda, Scarlett held on to her fear, as if it would keep her safe, but Tella could see her sister fighting to let it go. She really had changed during Caraval.
"You were right last night, when you encouraged me to give Julian another chance. I'm glad I went to the party, and I know I'll regret it if we don't go with him. But," Scarlett added, "if we go to Valenda, you have to promise you'll be careful. I can't lose you again."
"Don't worry. I swear it." Tella solemnly took her sister's hands and squeezed. "I enjoy my freedom way too much to let it go. And, while we're in the capital, I'll be sure to wear impossibly bright dresses so I'll always be impossible to lose."
Scarlett's mouth tilted toward a smile. Tella could see her sister trying to battle it, but then it transformed into a melodious laugh. Happiness made Scarlett even prettier.
Tella giggled with her until their smiles matched, as if worries were things made for other people. Yet Tella could not forget the letter in her pocket, reminding her of a debt to be paid and a mother who still needed to be saved.
Copyright © 2018 by Stephanie Garber
Trade PaperbackCompact DiscHardcoverDigital Audioe-Book Format
The "immersive and imaginative" (USA TODAY) games continue in the #1 NEW YORK TIMES bestseller LEGENDARY, the mesmerizing sequel to CARAVAL
Donatella and Scarlett Dragna escaped their cruel father and made it out of Caraval alive, but the games aren't over yet. What Scarlett doesn't know is that, in order to gain their freedom, Tella made a deal with a mysterious stranger and now it's time to pay.
Except what Tella owes is something that no one has ever been able to deliver: the true name of Caraval Master Legend. Tella's only chance at uncovering Legend's true identity is to enter the dangerous game of Caraval once more, and win. But what will she have to sacrifice to do that?
Don't miss FINALE, the stunning conclusion to the Caraval trilogy—out now!
IndieNext pick
Goodreads Choice Award finalist
"Themes of love, betrayal, family and forgiveness are explored as the narrative ratchets up the tension toward a conclusion that will leave readers clamoring for more. Fans of Caraval will love it, and new readers will be enthralled by this immersive and imaginative world." —USA TODAY
"Legendary is a whirlwind adventure that contains vivid, complex, and enchanting characters you'll want to follow to the last page." —BuzzFeed (Best YA Book of the Year)
"A fantastic world reminiscent of Harry Potter's Diagon Alley. Rather addictive . . . maybe even legendary." —The Minneapolis Star-Tribune
"The setting of the game is fantastic in its spectacle and intrigue, and Garber pushes her world building even further. . . . The pacing is impeccable, with urgency increasing to an almost breathless point as Tella runs from clue to clue, while bittersweet truths and devastating betrayals unfold." —The Bulletin, starred review
"A tour de force of imagination. Themes of love, betrayal, and the price of magic (and desire) swirl like Caraval's enchantments, and Dante's sensuous kisses will thrill readers as much as they do Tella. Dark, seductive, over-the-top: Characters and book alike will enthrall those who choose to play." —Kirkus Reviews
"Caraval was a rollercoaster ride of twists and turns, and the latest installment lives up to that standard and more. Garber succeeds marvelously in broadening this magical, seductive world." —New York Daily News
Praise for CARAVAL
#1 IndieNext Pick
A best book of the year (Entertainment Weekly, Teen Vogue, Publishers Weekly, Goodreads, BuzzFeed, and more)!
"The Hunger Games meets The Night Circus. Grade: A-." —Entertainment Weekly
"Impressive, original, wondrous." —USA Today
"Spellbinding." —US Weekly
"Magnificent. A spellbinding tale of love, loss, sacrifice, and hope." —Publishers Weekly, starred review
"Destined to capture imaginations." —Kirkus Reviews
"This twisty, terrifically fun page-turner is a must-have fantasy debut." —SLJ


When it comes to working out, you want to do what is best for your body. Part of your work out regimen should be more than what you are actually physically doing during each work out, but what you put into your body as well. Vitamins and supplements can really make a difference as well as aid your progress. You want to make sure you've got the right amounts of varying vitamins, for whether it's cardio, muscle building, or just building flexibility.
Vitamin E is important to boost an immune system, because those who work out and are consistently exerting themselves may need more of it in general than the average person. Vitamin E also contributes to cell signaling and regulate gene expression, both important parts to muscle building. Whether male or female, adding Vitamin E on top of your weight lifting exercises can make a difference.
Along with Vitamin E, protein is also a good choice for weight lifting and muscle building. Bodies turn excess protein into muscle, when you are working them at the same time. You can get extra protein through bars, shakes, or even just upping the amount of meats you eat.
Vitamin C, or ascorbic acid, strengthens tendons, blood vessels, bones and ligaments, which means your body is better prepared for working out in general. Because all kinds of exercise training tests these tissues, a good amount of vitamin C can really help. This is easy to come by and you'll always find a good deal in most multi-vitamins.
Vitamin B, and all of the vitamins in this family in general, help with metabolizing foods. Proteins, fats, and especially carbs are worked through and turned into energy with vitamin B, so this is very essential no matter what kind of working out you do. You need to get the food you eat metabolized into energy to keep your body going for the duration of your physical activity.
Vitamin D, the "sunshine vitamin" as a lot of people call it, is important for our bones in that it helps them maintain proper density so that you can avoid injury during work outs. Yes, taking the right high quality vitamins can actually help prevent injury, which is an important thing.
So before you start your next exercise program, make sure to invest in some good vitamins to help you out. It's important to have an entire system to get you through, not just depend on the exercises you are doing.


The American Sailing Association was founded in 1983 with a simply stated mission: to teach people to sail safely and confidently. Visit www.asa.com for more information.
Young Sailors: Are You an "Ocean Hero"?
Could Algae Save the World?
Ask Lauren: What Do I Do If I See an Animal Tangled in Plastic?


How does one determine runway orientation without a local wind rose?
We are planning to establish new airport, but then we have no wind rose analysis of the location.
How can we predict what's the right orientation for the runway that satisfies the 95.
Assuming that you are not bound by local topography and thus can build the runway in, theoretically any direction you like, there are a few things you can do. First, you could set up a small weather station and record some data. You could then use this data to determine your direction. You can also use a site like this one to see the historical wind/weather data in the area. This will help you get an idea of the prevailing winds at near by.
Not the answer you're looking for? Browse other questions tagged weather airport-design or ask your own question.
How common are cancelled landing attempts?
How do pilots respond to wind shear?
How does radar detect turbulence and wind speed?
How is wind measured at this small U.S. airport?
Are winds that are not from the prevailing wind direction more often gusty, and why?


text:
43025 Valusha este un asteroid din centura principală de asteroizi.

Descriere
43025 Valusha este un asteroid din centura principală de asteroizi. A fost descoperit pe  la Uccle de Eric Walter Elst și Sergij Ivanovič Ipatov. Asteroidul prezintă o orbită caracterizată de o semiaxă mare de 2,33 ua, o excentricitate de 0,16 și o înclinație de 2,5° în raport cu ecliptica.

Vezi și
 Lista planetelor minore: 43001-44000
 Centura de asteroizi

Referințe

Obiecte astronomice descoperite în 1999
Centura de asteroizi

redpajama_set_name: RedPajamaWikipedia


Mansha Pasha belongs to the young breed of actors in Pakistan, a talented actress who has worked in several serials and shows. The most prominent recent show which has is being telecast on Hum Tv Network is Madiha aur Maliha and Zindagi Gulzar Hai.
Watch these Mansha Pasha Wedding Pictures. Mansha recently got married this year in August to Asad Farooqi and somehow we missed the news and couldn't share it with our readers. Mansha is now happily settled with her husband and enjoying a smooth professional life on the other hand.
Before watching her wedding picture see below her full biography…..
Date of Birth ; 19th October 1987.
Husband Name ; Asad Faruqi.
Birth place ; Karachi, Pakistan.
Profession ; Actress, Producer and Model.


When the Stereophonics added a second acoustic stage to their latest tour performances – accessed via a long thrust from the main performance area – it presented a conundrum to the band's long-time technical crew: FOH engineer Dave Roden, and rental/production company, Capital Sound Hire.
With lead singer/guitarist Kelly Jones – exclusively on in-ears for the first time – preferring to be as far away from the sub energy as possible, Capital Project Manager Robin Conway set about reworking the traditional broadside cardioid array of Martin Audio MLX subwoofers into something that accommodated these new considerations. The solution was a central cardioid dual-loudspeaker cluster.
The general touring rig comprised 13 MLA elements per side and an MLD Downfill, with hangs of 12 MLA Compact on each flank for side fills. At the largest venue – Manchester Arena – the main hangs were increased to 15 MLA per side and an MLD, and the side hangs to 16 MLA Compact. Lip fills comprised six W8LM Mini Line Array.
As with the previous tour, Roden was joined at FOH by experienced MLA system tech Toby Donovan for the UK dates, having swapped mixing consoles for a DiGiCo SD5. The DiGiCo platform was maintained down in Monitor World where Harm Schopman was operating an SD10.
The MLA solution met the approval of the band, production manager Dave Nelson and the FOH sound team: 'As always, it was a pleasure working with Toby for the UK Mainland shows and also with Finlay Watt who kindly stepped in as MLA tech for the Irish dates,' Roden says.
'Big thanks as well to Harm and Stereophonics' own audio wizard Sam Cunningham for their constant help, support and patience, to Dave Nelson for bringing it all together seamlessly every time and to Martin, Robin and especially Keith Davis at Capital Sound Hire, for whom I have an endless amount of respect.


text:
Q: Test contain no key words New to Robot Frame Work, couldn't understand whats wrong!
Here I am trying to read a json file and the test is failing saying that there are no keywords, what have I done wrong?

A: Your test case name is the same as the keyword you defined. The test case does not have any step, just the name.
You need to add a step calling a keyword.

redpajama_set_name: RedPajamaStackExchange


text:
Ten humanitarian crises to look out for in 2018
IRIN's editors sketch out the gloomy-looking horizon for next year
جنيف، 1 يناير 2018
From the Rohingya to South Sudan, hurricanes to famine, 2017 was full of disasters and crises. But 2018 is shaping up to be even worse. Here's why.
The UN has appealed for record levels of funding to help those whose lives have been torn apart, but the gap between the funding needs and the funding available continues to grow.
And what makes the outlook especially bad for 2018 is that the political will needed to resolve conflicts, welcome refugees, and address climate change also appears to be waning. What a difference a year, a new US president, and a German election make.
Here's our insider take on 10 crises that will shape the humanitarian agenda in 2018 (See 2017's list here):
Syria's sieges and displacement
As Syria heads towards seven years of war and Western governments quietly drop their demands for political transition, it has become increasingly clear that President Bashar al-Assad will stay in power, at least in some capacity.
But that doesn't mean the violence or suffering is over: pockets of resistance are still being starved into submission and being denied aid – nearly three million Syrians still live in areas the UN defines as besieged or "hard to reach" (see: eastern Ghouta right now), while chemical weapons are deployed to horrifying effect.
There's talk of reconstruction where the fighting has fizzled out, be it in areas brought under the government's control or in cities like Raqqa, which is now controlled by Kurdish forces but has a mixed population that is beginning to come home, to utter destruction.
Investors are lining up for a slice of the rebuilding pie. But an average of 6,550 Syrians were displaced by violence each day in 2017. So what of the 6.1 million and counting displaced inside Syria – many sheltering in tents or unfinished buildings and facing another long winter – not to mention the 5.5 million refugees abroad? Will they have a say in how Syria is rebuilt? With reconstruction already a major bone of contention in peace talks and the EU planning to get involved in 2018, how this plays out is important and worth watching.
Congo unravels
You know the situation is bad when people start fleeing their homes, and it doesn't get much worse than the Democratic Republic of the Congo.
Here, violence in its eastern provinces has triggered the world's worst displacement crisis – for a second year in a row. More than 1.7 million people abandoned their farms and villages this year, on top of 922,000 in 2016. The provinces of North Kivu, South Kivu, Kasai, and Tanganyika are the worst affected and the epicentres of unrest in the country.
New alliances of armed groups have emerged to take on a demoralised government army and challenge President Joseph Kabila in distant Kinshasa. He refused to step down and hold elections in 2016 when his constitutionally mandated two-term limit expired – and the political ambition of some of these groups is to topple him. These rebellions are a new addition to the regular lawlessness of armed groups and conflict entrepreneurs that have stalked the region for years. It is a confusing cast of characters, in which the army also plays a freelance role and, as IRIN reported this month, as an instigator of some of the rights abuses that are forcing civilians to flee.
As we enter 2018, more than 13 million people require humanitarian assistance and protection – that's close to six million more people than at the start of 2017. Over three million people are severely food insecure in the Kasai region alone, their villages and fields looted. Aid is only slowly trickling in. The $812 million appeal for Congo is less than 50 percent funded. That lack of international commitment represents the single largest impediment to the humanitarian response.
Yemen slips further towards famine
If we repeat the words "world's worst humanitarian crisis" so often that they starting to lose gravity, here are a few numbers that might help hammer home just how grim life has become after more than two and a half years of war in Yemen, a country of more than 29 million: 8.4 million people are on the verge of starvation; 400,000 children have severe acute malnutrition (that's as bad as it gets), and more than 5,500 civilians have been killed.
Last January, we warned Yemen was at serious risk of sliding into famine. That now seems a near-certainty and may be unfolding right now, with the Saudi Arabian-led coalition continuing to restrict or at least delay commercial imports of food and fuel (among other goods), causing prices to shoot up and meaning those on the margin no longer have enough cash to buy the bare necessities.
And what of that cholera epidemic that killed 2,226 and infected nearly a million since April before receding? Nobody has been vaccinated, fuel shortages mean less clean water, and the rainy season is coming. All of this combines to create a real risk that the disease will make a comeback. Diphtheria is on the rise, too. None of this happens in a vacuum: without proper nutrition, Yemenis are increasingly susceptible to illness.
South Sudan – it could get even worse
A much-anticipated ceasefire in South Sudan didn't last long.
It came into effect at midnight on Christmas Eve, and a few hours later government and rebel forces were fighting around the northern town of Koch in Unity State. The violence hasn't derailed the peace talks underway in Addis Ababa, but it does point to how difficult it will be for the internationally-backed diplomatic process to shape events on the ground.
The ceasefire is between President Salva Kiir and several rebel groups, but confidence is low that negotiations can bring a quick and decisive end to a war entering its fifth year.
South Sudan has fragmented, with a host of ethnic militias emerging with shifting loyalties. The various members of this so-called "gun class" all want a seat at the table, in the belief that any future agreement will be based on a power-sharing deal and a division of the country's resources along the lines of the last failed settlement.
The international community lacks leverage and neighbouring countries don't have the unity of purpose necessary to achieve a broad-based and sustainable peace agreement.
What that means is that more refugees – on top of an existing two million – will continue to pour across the country's borders as the fighting season resumes.
It also means some seven million people inside the country – almost two thirds of the remaining population – will still need humanitarian assistance; hunger will also continue to threaten millions as a result of the war, displacement, and collapse of the rural economy. And yes, there will be the threat of renewed famine.
One final ingredient in the brew of despair is that the humanitarian community's access to those in need will be constrained by both the prevailing insecurity and the government's cynical taxation of aid operations.
CAR – where humanitarians fear to tread
There are many reasons why Central African Republic was officially the unhappiest country in the world in 2017.
You can start with the 50 percent increase in the number of displaced, bringing the total to 633,000 people. Then there are the more than two million hungry people, and the half a million who have figured it's just too hard to stay and have left for neighbouring countries.
It's not much fun being an aid worker either. In November another humanitarian worker was killed in the north of the country, bringing to 14 the number to have died this year. The level of violence has forced aid agencies to repeatedly suspend operations as their personnel, convoys, and bases are deliberately targeted.
Behind the insecurity is a four-year conflict between competing armed groups that neither a weak government nor an under-staffed UN peacekeeping mission can contain. It pits mainly Muslim ex-Séléka rebels against Christian anti-Balaka, but some of the worst fighting has its roots in the splintering of the Séléka coalition and a feud between former allies.
The violence across the country boils down to the lucrative control of natural resources and the taxes the groups raise from checkpoints. Such is the insecurity that the government's writ doesn't even cover all of the capital, Bangui.
Rohingya refugees in limbo; forgotten conflicts simmer elsewhere in Myanmar
After a catastrophic year in which more than 655,000 people were driven out of Myanmar's Rakhine State, it's hard to imagine 2018 could go any worse for the Rohingya minority.
But, with nearly a million Rohingya refugees crowded into overloaded settlements in southern Bangladesh, the new year brings a host of new questions.
The sudden exodus of refugees captured the world's attention, but as the crisis shifts from emergency response to long-term survival, will the focus – and funding – keep pace with the pressing needs on the ground? Can the fragile settlements withstand a significant storm, or even the seasonal monsoon rains that will fall in a few short months? And will the Bangladeshi and Myanmar authorities try to make good on a plan to repatriate Rohingya refugees despite warnings from any number of aid groups, rights monitors, and UN agencies, and a troubling history of less-than-voluntary returns?
While Rakhine State smoulders, long-simmering conflicts continue to fly under the radar elsewhere in Myanmar. Clashes between Myanmar's military and ethnic armed groups in the country's north have escalated, largely out of the public spotlight. In northern Kachin and Shan states, some 100,000 people have been uprooted since 2011, when a government ceasefire with the Kachin Independence Army collapsed. Roughly 40 percent of these people live in areas outside government control. But Myanmar has also put limits on aid access to areas even under its authority, mirroring the more publicised restrictions in place in Rakhine. Buried somewhere is Myanmar's long-stalled peace process involving myriad ethnic armed groups operating across the country. A new round of talks is set for later in January. But with only a handful of armed groups on board with a tenuous ceasefire agreement and other key players excluded entirely, a politically negotiated peace remains elusive.
Afghans return to flaring conflict
Afghanistan begins 2018 facing another volatile year.
Conflict has displaced more than one million Afghans over the last two years. But added to this are the ever-growing numbers of Afghans returning from (or rather kicked out of) Europe and neighbouring countries like Pakistan and Iran. They're coming back to a country that the UN in August concluded was no longer in "post-conflict" mode but in active conflict once again, one where a resurgent Taliban and emboldened Islamic State-aligned militants vie for control as the government's grasp weakens.
The problem can be summarised in one ominous chart, which shows US military estimates that the Afghan government has influence in less than 57 percent of the country's districts:
The raging conflict has had disastrous impacts on Afghan civilians. Last year saw civilian casualties soar to near record-high levels, and an escalating number of people were killed in attacks targeting places of worship – something the UN has called a "disturbing" new element to the violence. Healthcare continues to come under siege, with skirmishes severing access to hospitals and clinics, and aid workers caught in the crossfire.
The next 12 months could prove an even greater challenge. January is the start of Afghanistan's food "lean season", which will hit those already uprooted by conflict particularly hard. It's now begrudgingly accepted that a viable peace settlement must include the Taliban – a once unthinkable suggestion – but there has been "no meaningful progress". With parliamentary elections scheduled for July 2018, the battle for control of Afghanistan will continue on multiple fronts as the snows melt and the fighting resumes in earnest.
Venezuelan exodus to strain neighbours
The descent of Venezuela from oil-rich powerhouse to economic basketcase has been well chronicled.
Less thoroughly reported, partly due to media restrictions under the increasingly authoritarian rule of Hugo Chávez's successor, President Nicolas Máduro, has been the extent of the humanitarian crisis. Shortages of basic goods and soaring inflation have led to growing reports of severe childhood malnutrition in addition to a general healthcare crisis, and to more than a million Venezuelans fleeing the country.
If 2017 was the year when the scale of crisis within Venezuela began to reveal itself, 2018 is set to be when the full effects are felt beyond its borders. The political situation underpinning this crisis is only likely to worsen. Elections, slated for December 2018, are expected to be brought forward and foisted upon a weary, hungry, and increasingly desperate electorate that is sharply divided. Unrest or government crackdowns will only send more Venezuelans pouring over the border. There are already signs that regional hospitality is wearing thin and of emergency camps being prepared. The International Monetary Fund predicted that Venezuela's triple-digit inflation could soar to more than 2,300 percent in 2018. As the year closed out, opposition parties were barred from the election, a main opposition leader was banned from political activity for 15 years, and violent pro-democracy protests rocked the capital, Caracas. None of this augurs well.
Libya: Africa's giant holding cell
An AU-EU summit at the end of 2017 seemed to offer a glimmer of hope for the 700,000 to one million migrants stuck in the nightmare that is Libya.
It produced a plan to repatriate those who want it, and to move others from squalid detention centres into better conditions.
Some flights home did subsequently take off, and a first group (of 162 refugees and migrants from Eritrea, Ethiopia, Somalia, and Yemen) was even evacuated by the UN on 22 December from Libya to Italy. But we've yet to see how this scheme will play out, and there are some serious obstacles. Many migrants have nowhere safe to return to, and it's not clear how a UN-backed government that controls little in the way of territory or popular support will manage to move and protect migrants in a country with multiple governments, militias, and tribes.
That the meeting even got press (in large part thanks to a CNN film of what appeared to be a slave auctions) in an oft-ignored country is a sign of how little the world cares about the mostly sub-Saharan African migrants in Libya, for whom kidnapping, extortion, and rape have become the norm.
European policy has largely focused on keeping migrants from boarding boats in the Mediterranean or reaching their shores – creating a situation that is bad enough for Libyans and shockingly worse for Africans. At the summit, French President Emmanuel Macron mooted a military and police initiative inside Libya, plus UN sanctions for people-smugglers. How this could actually work is anyone's guess, and it seems unlikely to get at the source of many migrants' woes: the lack of legal avenues to get out of the desperate situations that brought them to Libya's hell in the first place.
A year of turmoil in Cameroon
It's taken just over a year for political agitation in Cameroon's anglophone region to turn into armed opposition against the government of President Paul Biya.
Separatism was only a fringe idea until the government cracked down hard on protesters demanding greater representation for the neglected minority region. Now, government soldiers are being killed, Biya is promising all-out war, and thousands of refugees are fleeing into neighbouring Nigeria.
Anglophone Cameroon is becoming radicalised. Refugees recounting experiences of killings by the security forces talk of revenge, and commentators worry that the opportunity for negotiations with more moderate anglophone leaders – those pursuing a policy of civil disobedience and diplomatic pressure on Yaoundé – may be rapidly shrinking.
If the government believes there is a military solution to the activists' demands for an independent "Ambazonia", made up of the two anglophone regions of western Cameroon, they may well be mistaken. Where the separatists' training camps are being established, next to the Nigerian border, is a remote and heavily forested zone – ideal for guerrilla warfare.
Biya, 85 in February and in power for the past 35 years, is standing in elections once again in 2018. The "anglophone crisis" and the potential of an even larger refugee exodus will not only leave him politically damaged but could be regionally destabalising, especially as Nigeria faces its own separatist challenge.
il-oa-as/ag


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There are numerous considerations to be made regarding the very rewarding and satisfying vocation of physical therapy. These considerations need to be made before even initiating your career journey. The road to becoming a physical therapist can be discouraging with many challenges. However, this can be what makes the journey interesting and challenging! This guide will offer details on the essential steps to become a physical therapist in neurology.
The vital job of a physical therapist is to assist people who have lost the use of their body due to trauma or disability, get that function back. When evaluating the job of a physical therapist in neurology, it is important to think about the numerous tasks and challenges one may experience.
Some therapists within this business manage patients suffering from severe medical conditions requiring complex treatment, including victims of brain and spinal cord injuries or those with Parkinson's disease. The proficiencies you will need to care for these individuals long-term will be acquired in an academy setting and on the job.
Although it is feasible to become a physical therapy assistant and progress from this position using a Bachelor's degree, it is suggested that one receive a postgraduate degree in a medical field. This educational experience is important. You wont have success without it. This applies specifically to the field of neurology which demands intimate knowledge of more challenging conditions.
Make sure to get admission info from Miami FL schools early in the process!
To become a physical therapist you're going to need to gain knowledge in the field. While you will need to complete your post graduate residency, you might need to consider volunteer work at rehabilitation centers during the course of your undergraduate study. You are even better off if the clinic provides services for neurological rehabilitation, which should help you to obtain even greater experience. The hours of voluntary work can contribute to the graduate residency.
Identifying someone experienced as a physical therapist is going to be very good for your success in graduate school. Understanding and guidance on the profession and on the physical therapy occupation are only a couple advantages that your mentor can offer you.
Gaining your state certification is one of the last steps to becoming a physical therapist. In any state you will be required to carry out licensing exams for certified physical therapy associations before being able to practice. In fact, one can only practice as a licensed therapist once certified in a minimum of two separate states. Don't be dissuaded by the challenge. The fulfillment of a satisfying occupation is well worth it.


Internships for students become a training activity under the supervision of the Faculty, the goal of which is to apply and complete the academic formation acquired, encouraging the professional skills that prepare for professional activities which facilitate the employment of them.
The framework of these activities is called educational cooperation agreements, regulated by Royal Decree 592/2014 which regulates the external academic practices of college students.
Through educational cooperation agreements, the University gives companies the opportunity to take on students in their final year so that they are able to gain practical professional experience.
More than 300 students of the Barcelona School of Informatics take part in the educational cooperation agreement of the Informatics Engineering degree and different Masters set by the Faculty.
A total of 900 hours of internship can be done by a student in the same academic year.
The academic year for agreements starts on 16th of September until 15th of September the following year.
It is an indispensable condition for the student to have passed at least half of the credits on the course they are studying to participate in an agreement.
The remuneration students received is paid directly by the company.
For students it is income from their work for third parties and is therefore subject to personal income tax.
The income tax that company must withhold is at least a 2%, because an educational cooperation agreement is considered to be equivalent to an employment relationship lasting under a year. The company must provide the student with a tax certificate to this effect.
Agreements signed as of 2012/2013 year will have an invoice of 15.7% for administrative services, furthermore VAT will be 21%.
Companies must include, from the date of 1th of July 2013, students who sign an agreement in the Social Security system obligatorily. More information.
Faculty won't establish agreements with companies whose invoices are not paid.
It is compulsory to carry out the agreement to the Faculty before the date of the internship.
Fill in, print and sign the agreement, 3 first pages (all fields are compulsory). Company and student must be sign three copies.
Fill, print and sign by the tutor the training plan (students of degree) or the work plan (students of Master).
Take to the agreements office the copies of the agreement plus the training plan, so that it can be registered.
Agreements without a work plan will not be accepted.
Companies should take into account the students of the Informatics Engineering degree and MAI, MEI and MIRI can choose between a curricular internship (implies a Final Project Degree or a Final Master Thesis, and a recognition of credits) or extracurricular.
In case as an agreement is cancelled, it will only be required to receive a low diligence by email to: .
Agreements can be done in collaborative entities, such as companies, national and international public and private institutions, as well as in the Faculty.
Considering the academic internship formation, they will not be subject to contractual employment obligations, or its content cannot be a substitution of a job benefit.
They are not involved either the study plan or academic record. However, they will incorporate to European Supplement to the university degree of the student.
The minimum loan of the internship subject and the Degree Final Project is 735 hours.
When an agreement starts, the Degree Final Project modality B needs to be registered (The Degree Final Project will be registered if the student has passed all compulsory subjects and a minimum of three compulsory subjects of the specialisation).
The center will do a pre-register (12 optative ECTS). The official registration of the subject is made simultaneously with the Degree Final Project registration.
The Faculty of Informatics reserves the right to participate in an agreement, as well as an existing agreement renewals, when the academic performance of the student is not adjusted to the minimum established: an academic parameter (it is known as the quoficient between credits students has passed and credits students has registered) superior to 0,50.
In the first date of the agreement, student must have passed 50% of credits on the course they are studying.
Students must have subjects registered or either the Final Project.
In the first date of the agreement, student must have passed 15 credits on the master.
Students must have subjects registered or either the Final Tesis.
The Faculty does not accept internships when the tasks involved are different from the functions of an Informatics Engineer.
The tutor's report of the Business Company or Institution.
In case of doing a curricular internship the student has to deliver the reports before the Final Project lecture.
These documents are essential for the evaluation of the internship.
From the Formative plan proposed initially, the tutor's report of the Business Company or Institution and the student report will evaluate the internship as favourable or unfavourable.
The Final Project registration must be done in the previous quarter to the Final Project inscription.
The final result from an internship with a favourable evaluation, will be the obtained in the Final Project. In the case of an unfavourable obtained result or not to have the Final Project registered in the subsequent quarter of the initial internship, the result will be a failure.
Remind you the Final Project in B modality is defended in the first tribunal meeting after the finalization of agreement in the business company which has done.
Royal decree 592/2014 of 11th July, which regulates the internship of university students.
Governing board agreement 30/2015, which approves the internship regulation of UPC. Document approved in 10th February 2015.
Regulations for external academic placements and Final Project Regulation (GEI, MAI, MEI, MIRI).


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Investigate the origin, maintenance, and organization of biodiversity and how organisms interact within the natural world. You'll develop an understanding of core biology concepts and principles, and gain practical experience in the laboratory, field, and classroom, where you'll develop computer and communication skills.
Why this program?
Work closely with faculty members who supervise independent research.
Participate in lab-based or field research at study sites in diverse forests, grasslands, lakes and rivers, and agroecosystems.
Participate in projects ranging from quantifying biodiversity in soils, to modelling impacts of human activity on wildlife, to the foraging behaviour of wild predators.
Join the local student chapter of The Wildlife Society to take advantage of increased networking, career development, and learning opportunities.
Campus: Okanagan
Faculty: Irving K. Barber Faculty of Science
Degree: Bachelor of Science
Honours	Yes
Ecology and evolutionary biology is an interdisciplinary field that draws on natural history, behavior, genetics, mathematical, and environmental sciences. It is a College of Applied Biology accredited program.
By studying Ecology, you master the tools needed to understand natural systems and improve the impact human activity has on the natural world. Studying evolutionary biology provides a focus on the origin and maintenance of biodiversity, an understanding of the adaptive processes that explain reproductive tactics and animal behaviour and the tools required for investigating ongoing evolutionary processes in natural systems.
In EEBI undergraduate studies at UBC Okanagan, you can complete a Bachelor of Science (BSc) in ecology and evolutionary biology. The BSc program offers a major and honours in ecology and evolutionary biology.
Experiential learning and research
This program offers a wide variety of foundational and advanced courses that explore topics ranging from the fundamental processes underlying adaptive evolution, speciation, and extinction to techniques used by wildlife ecologists.
The Irving K. Barber Faculty of Science also supports student research through the Undergraduate Research Awards, which allow students to carry out their own projects under the supervision of world-class researchers over the summer months. There are also a number of other awards which provide opportunities for students to work with professors on their research.
You also have the opportunity to take your studies abroad with the Go Global program and the Exchange and Research Abroad program, or participate in original research – either your own or a professor's in your field.
Irving K. Barber School Faculty of Science Undergraduate Research Awards
Biology Course Union
UBC's Okanagan campus is home to a number of world-class research facilities, including the Okanagan Institute for Biodiversity, Resilience and Ecosystem Services (BRAES). BRAES is a consortium of UBC faculty members and students, collaborators and partner organizations working together to advance research and teaching in conservation and ecology.
Okanagan Institute for Biodiversity, Resilience, and Ecosystem Services
The Centre for Microbiome and Inflammatory Research
BIOL 116 - Biology for Science Majors I
First of a pair of courses that introduce students to the biological concepts necessary to continue into second-year biology. Covers evolutionary theory and its underlying genetic basis, basic cell biology, plant and animal nutrition, and energy acquisition. Credit will be granted for only BIOL 116/125 or BIOL 117/122.
BIOL 125 - Biology for Science Majors II
Continuation of BIOL 116. Introduction to biological concepts necessary for second-year biology. Physiology of reproduction, gas exchange, inter-organ transport, inter-organ coordination in plants and animals, and excretion and movement in animals. Ecosystem, population, community, and behavioural ecology are discussed.
CHEM 111 - Principles of Chemistry I
Stoichiometry, atomic and molecular structure, chemical periodicity, gases, liquids, solids, and solutions. Not open to students with Chemistry 12.
MATH 100 - Differential Calculus with Applications to Physical Sciences and Engineering
Derivatives of elementary functions, limits. Covers applications and modelling: graphing and optimization.
BIOL 265 - Principles of Genetics
Mendelian genetics, gene expression, recombination, mutation, evolution, and molecular techniques. Examples will be drawn from both eukaryotic and prokaryotic systems.
BIOL 201 - Introduction to Evolution and Ecology
Fundamental processes underlying adaptive evolution, speciation, and extinction. Methods used to reconstruct the evolutionary histories of, and relationships among, groups of organisms. Factors determining the distribution and abundance of organisms. Competition, predation, and an exploration of processes that promote species coexistence and lead to the maintenance of species diversity.
BIOL 202 - Introduction to Biostatistics
Introduction to statistics, with emphasis on the application of commonly applied parametric and non-parametric statistical methods in the biological sciences. Use of computer software to manage data, conduct statistical analyses, and report findings in publishable formats.
CHEM 203 - Introduction to Organic Chemistry
Structure, bonding, and physical properties of aliphatic and aromatic compounds; conformational analysis, stereochemistry, and NMR spectroscopy; substitution and elimination reactions of alkyl halides; ethers, epoxides, aldehydes, ketones. Credit will not be granted for only one of CHEM 203 or CHEM 213.
BIOL 301 - Evolutionary Principles and Methods
An exploration of the field of Evolutionary Biology as an ongoing scientific endeavour. Current research methodology and development of concepts relating to the study of evolutionary change, adaptation, and the history of life will be examined.
BIOL 308 - Population Biology
Introduction to the study of plant and animal populations. Demography, single species growth, competition, predation, and natural selection.
BIOL 311 - Biochemistry I
Structure and function of proteins, carbohydrates, lipids, and nucleic acids. Principles of thermodynamics and enzyme reaction mechanisms. Enzyme kinetics. Credit will only be granted for one of BIOL 311 or BIOC 304.
BIOL 354 - Cell Physiology
The cell is the fundamental unit of life. This course delineates a number of shared biological processes conducted at the cellular level and similar across a wide range of organisms (e.g., acquisition of usable energy, energy storage, transport processes, irritability, and contractability).
GEOG 307 - Advanced Biogeography
Present distribution and diversity of plants and animals; factors underlying the development of modern biogeographic realms; dispersal, colonization, and invasion; prehistoric and modern evolution and extinction; biodiversity; island biogeography; conservation biogeography.
BIOL 459 - Behavioural Ecology
Ecological and evolutionary basis for behaviour, the role of behaviour in enabling an organism to adapt to its environment. Topics include optimization and game theoretic approaches, foraging, sociality, mating, and parental care. Laboratory provides opportunities to explore concepts covered in lecture.
BIOL 460 - Population Genetics
Concepts in empirical and theoretical population genetics. Primary processes shaping genetic variation within and among populations. Methodologies for measuring genetic variation in nature, and practical applications of population genetic principles to genomics, molecular evolution, human evolution, and conservation biology.
BIOL 401 - Spatial Ecology
Spatial patterns in ecology, exploring ways to describe variation and mechanisms that give rise to patterns. Dispersal, metapopulation and source-sink dynamics, connectivity and fragmentation, heterogeneity, disturbance, edges, and dynamics of geographical ranges.
BIOL 422 - Conservation Biology
Scientific basis of conservation biology. Analysis of demographic data, population models, and extinction risks. Examine complex habitat, landscape, genetic, and trophic interactions that affect populations. Conservation approaches including habitat planning, reserve design, surrogacy, and policy.
BIOL 468 - Molecular Approaches in Ecology and Evolution
Techniques for collecting molecular and population genetic data. Applications in ecology, evolution, and conservation. Characteristics of molecular markers, associated analytical approaches, emerging genomic technologies, and case studies.
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UBC's Okanagan campus
Life at UBC's Okanagan campus
UBC's Okanagan campus is renowned for its research opportunities and access to professors. On a tight-knit campus like the Okanagan's, you'll be able to work closely with award-winning faculty and make meaningful connections with your peers. You'll also have access to clubs like the Biology Course Union.
A UBC education will introduce you to people and ideas from around the world, open doors to new opportunities, and take you places you never imagined. You'll graduate not only with expertise in your chosen field, but with the skills you need to continue growing, learning, and evolving with your career over time.
Degree-specific requirements: Science
IB Math Analysis and Approaches SL or HL, or IB Math Applications and Interpretations HL. (IB Math Applications and Interpretations SL, or IB Math Studies, are not acceptable.)
One of IB Biology, IB Chemistry, or IB Physics
Grade 11 or equivalent Chemistry
Grade 11 or equivalent Physics is strongly recommended
Note: Grade 11 Chemistry and Physics requirements listed are only relevant to students who are not completing the equivalent IB Diploma Chemistry and/or Physics courses.
For students studying outside of Canada, some examples of courses that may be accepted as Grade 11 equivalents are junior-level courses for American students, and IGCSE and O Level for those following British-patterned curricula.
10 things you never knew about UBC
Meet Nagi, a Biology major and Collegia assistant on UBC's Okanagan campus


Local Investor Peter Hunt of BahamaLand Investments made a financial contribution to the combined Grand Bahama Carnival Company on Thursday October 2nd for the development of prototype costumes for the highly anticipated Bahamas Junkanoo Carnival set for May 7-9, 2015.
Executives at the Grand Bahama Port Authority, Limited (GBPA) announced plans for Value Added Tax (VAT) readiness training for businesses to commence on Grand Bahama in the coming weeks.
What Is Going On With These Issues?
Guests arriving from Canada had to be relocated as the new Memories Resort, which was expected to open, was not quite ready to receive them.
The chief science officer from the Okyanos Heart Institute, Dr. Leslie Miller, will address the International Stem Cell Society Global Conference in Freeport, Grand Bahamas, February 19-22, 2014.
The Go-Trade Business Expo 2013 is set for Freeport this October 26th at the Sir Jack Hayward High School, offering businesses a networking, business-building opportunity.
Freeport Oil Company Limited (FOCOL) has broken its silence surrounding the 'bad gas' issue and is now asking customers with pending claims to be patient.
Tragedy struck on the streets of downtown Freeport when a vehicle – carrying three children and their mother – was severely mangled, nearly beyond recognition.


Brochure design is critical in the world of marketing and graphic design, yet can be challenging to execute successfully. The Big Book of Brochures is an extraordinary visual collection featuring work from top designers around the globe. It offers hundreds of ideas, pages of inspiration, and loads of advice for professional graphic designers and students alike. This book provides ideas on corporate and product literature, annual reports and direct marketing, and new media, providing a wellspring of ideas for designers creating client brochures. It offers recommendations for choosing type, layout, photo treatments, and much more.
Covering a variety of styles, from classic to modern, sophisticated to conceptual, The Big Book of Brochures is an indispensable brainstorming resource for any designer looking to create innovative, high-quality brochures.


text:
package com.github.mvollebregt.wildmock.test.robustness;

import com.github.mvollebregt.wildmock.fluentinterface.TriggerA;
import com.github.mvollebregt.wildmock.fluentinterface.WhenA;
import com.github.mvollebregt.wildmock.test.helpers.ClassToBeMocked;
import org.junit.jupiter.api.Test;

import static com.github.mvollebregt.wildmock.Wildmock.*;
import static org.junit.jupiter.api.Assertions.assertNotEquals;

public class ReuseOfWhenAndTriggers {

    private final ClassToBeMocked mock = mock(ClassToBeMocked.class);

    @Test
    public void testReuseTrigger() {
        TriggerA<Integer> trigger = trigger(mock::consume, Integer.class);
        assertNotEquals(trigger.with(x1 -> x1 >= 0), trigger.with(x2 -> x2 <= 0));
    }

    @Test
    public void testReuseWhen() {
        WhenA<Integer, Integer> trigger = when(mock::identityFunction, Integer.class);
        assertNotEquals(trigger.with(x -> x >= 0), trigger.with(x -> x <= 0));
    }
}

redpajama_set_name: RedPajamaGithub