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Five game-changing policies for integrative healthcare of 2016
Katherine Shagoury
Integrative medicine was the focal point of a number of this year's healthcare policies and regulations. From the opioid crisis to regulating naturopaths, click through to see which five policies from 2016 that we chose to highlight in our end-of-year round-up.
Editor's note: This is the third of a four-part series where IntegrativePractitioner.com will ring in the New Year by looking back at news, policies, trends, and other topics that resonated with our audience in 2016. Check back next Tuesday to see our round-up of this year's top trends.
1. Action on pain, opioids and non-pharmacologic approaches
National and state policy related to nation's opioid epidemic continue throughout 2016. In February, the proposed Obama budget includes $1.1 billion for a campaign that is notably absent of reference to non-pharmacologic and integrative approaches. The CDC Guideline for Prescribing Opioids for Chronic Pain earned a letter of support from the American Chiropractic Association (ACA), commending the agency for recommending the use of conservative forms of pain management as an initial treatment option. The Integrative Healthcare Policy Consortium (IHPC) also responded to the CDC draft. They referenced the strong Joint Commission language on non-pharmacologic approaches. They cite the policy brief developed for PAINS through the Academic Collaborative for Integrative Health, Never Only Opioids.
State medical societies are weighing in split on the topic. The Massachusetts Medical Society guidelines don't include a whisper on alternatives to pharma. Yet, denial of the evidence continues. The American Hospital Association's Hospitals and Health Networks is as dismissive of the non-pharma literature in this review article. Better news came out of an interprofessional group in Minnesota. Organizations representing medical doctors, nurses and pharmacists announced a Joint Statement on Pain Management. One recommendation is to "collaborate using a multi-disciplinary approach to identify all treatment options including pharmacologic and non-pharmacologic modalities."
Read it again: https://www.integrativepractitioner.com/whats-new/news-and-commentary/integrative-health-policy-shorts-february-2016/
2. Integrative treatments for back and spine conditions
Oregon is the first jurisdiction in the U.S. to adopt a policy offering non-pharmacologic, integrative approaches as a first option for those seeking to manage pain conditions. The Oregon Health Authority (OHA) had previously accepted naturopathic physicians as leaders of their version of a PCMH called a Coordinated Care Organization.
Beginning July 1, 2016, the OHA—following recommendation from the state's multidisciplinary Health Evidence Review Commission panel—began including covered services of acupuncturists and chiropractic doctors. Though the focus was back pain, more common non-pharmacologic approaches, such as cognitive behavioral therapy and physical therapy, were also included. Click here for a fact sheet.
Read it again: https://www.integrativepractitioner.com/whats-new/news-and-commentary/oregon-integrative-collaborative-preps-stakeholders-historic-medicaid-painopioids-program/
3. Obstetricians soften views on midwifery and homebirth
The anti-homebirth vehemence of the American Congress of Obstetricians and Gynecologists (ACOG) may partly explain why midwifery is rarely included as part of the dialogue around integrative health and medicine. This distance is despite the alignment of the principles and practice of midwifery with core integrative values: respecting the whole person; affirming natural process; the patient-centered right to choose. Recent actions from ACOG suggest that finally a thaw is beginning.
The changes are itemized in a e-newsletter from the National Association for Certified Professional Midwives (NACPM). The title features the most recent action: "ACOG Issues Revised Opinion on Home Birth." ACOG's updated Committee Opinion on Planned Home Birth reiterates the ACOG perspective that out of hospital births are safest in birth centers. But the changes add that "each woman has the right to make a medically informed decision about delivery."
Read it again: https://www.integrativepractitioner.com/whats-new/news-and-commentary/obstetricians-soften-views-on-midwifery-and-homebirth/
4. Pennsylvania regulates naturopathic doctors
In a rare win for the naturopathic physicians, in early November, the Pennsylvania Governor Tom Wolf ended a 16-year battle for recognition in the state by signing a law to regulate the profession.
In a release from the Association of Accredited Naturopathic Medical Colleges (AANMC), the legislative chair for the Pennsylvania Association of Naturopathic Physicians (PANP), Heidi Weinhold, ND said the governor's approval will throw open the doors for more Pennsylvania students to choose this academic course of study. "Then, they can return home from a four-year graduate program to set up a practice as a naturopathic doctor," she said. "This is a historic day for naturopathic medicine."
Read it again: https://www.integrativepractitioner.com/whats-new/news-and-commentary/breaking-ama-logjam-pennsylvania-regulates-naturopathic-doctors/
5. AIHM and European anthroposophic group announce "Stuttgart Declaration on Integrative Health and Medicine"
Perhaps the most significant policy related move grew out of the Academy of Integrative Health and Medicine's (AIHM) first global foray, the June 2016 integrative conference in Stuttgart that drew 650 practitioners. Among those presenting was Zhang Qi, MD, who heads the World Health Organization's (WHO) traditional medicine strategy, and parallel leaders from the Pan American Health Organization. At the meeting, AIHM's director of education Tabatha Parker, ND and others announced a historic Stuttgart Declaration on Integrative Health and Medicine.
The document called on government agencies and non-governmental organizations, such as the WHO, to adopt and promote an integrative model. A petition at Change.org gathered 6,355 signatures by November 6, 2016. This was part of a global connectivity that AIHM leaders initiated through attendance at the WHO General Assembly.
Read it again: https://www.integrativepractitioner.com/whats-new/news-and-commentary/aihms-steps-toward-becoming-interprofessional-big-tent-integrative-health/
Resolve to get involved with IntegrativePractitioner.com!
We at IntegrativePractitioner.com aim to support the wide spectrum of integrative healthcare professionals in becoming more successful in their practices to effect positive improvements in the current standards of healthcare, policy, and to strengthen the common ground among all constituents. Our site is the destination for business networking relationships among companies and practitioners. Want to get more involved with our community in 2017? Here are a few ways you can make that resolution happen:
Submit your content. IntegrativePractitioner.com is currently accepting content from those who are interested in distributing relevant published research or articles to our audience. E-mail [email protected] for more information.
Join our social media. Engage with your peers in integrative medicine through our informal networking platform via LinkedIn. Click here to become a member. Check us out on Facebook and Twitter, too. We encourage you to ask questions and communicate with us through all of our social media channels.
Sign up for our newsletter. Stay up to date with all news, commentary, and other tools we have to offer in this weekly e-mail. Click here to subscribe.
Katherine Shagoury is the editor of Integrative Practitioner. She brings a decade of experience creating and managing content for national healthcare audiences as a digital editor and professional journalist, including serving as managing editor for a popular medical billing and coding association and as a reporter for the Boston Globe, Boston.com, and USA Today. A certified personal trainer and nutrition coach with the National Academy of Sports Medicine, a certified group fitness instructor with the Athletics and Fitness Association of America, a certified barre instructor, and a TRX qualified trainer, her passion for and commitment to healthy living fuels her enthusiasm for supporting the integrative healthcare community.
Ten integrative healthcare trends to watch in 2017
A naturopathic guide to integrative treatment and policy: A new therapeutic order for 2017
Top 10 IntegrativePractitioner.com news and commentary of 2016
Oregon integrative collaborative preps stakeholders for historic Medicaid pain/opioids program
Breaking the AMA logjam? Pennsylvania regulates naturopathic doctors


We're only two days into May, so this is gonna be the shortest round-up ever.
Oh yeah, and I'm totally in my friend Elizabeth's studio here. Isn't it GORGEOUS?
This is what I had planned to wear Thursday 🙂 I LOVE wearing this maxi! It's so swishy and fun and I feel so elegant. Gonna be hard not wearing this every day, ha!
So that's it for week 1! Like I said, pretty short 🙂 We'll get it really cranking next week, I imagine.
Just so this post isn't all super short, let's talk about my tshirt I'm wearing today! This is the Nettie pattern. If you hadn't heard of it yet, that's cos it was just recently released so it's brand spankin' new!
Nettie is actually designed to be a bodysuit… you know, one piece, snaps at the crotch, that sort of thing. I was asked to be a pattern tester, and I agreed under the premise that I could make mine into tshirts. Bodysuits and I just don't get along (although, after reading what Heather wrote… I'm wondering if I might like them in winter, for that no-cold-creeping-on-my-midriff factor. Hm.), plus, it's always nice to see if the pattern has additional options, yeah? So here are a couple of the Netties I made – I actually made 4, but I won't bore you with all of them (I'm sure they'll pop up at some point this month).
I love pretty much everything about this pattern. I love that it comes with multiple options – high neck, scoop neck, high back, scoop back, REAL LOW scoop back, short sleeves, long sleeve, elbow-length sleeves.. not to mention, bodysuit/tshirt/dress. Whew! I also love how fitted it is. No positive ease here!
You do have to be mindful of the fabric you're using, because of the negative ease factor. This mint Nettie is made using a rayon knit (it's the same stuff I used to make my MCall's 4488, I've been hoarding the remainder in my stash for quite a while now!), and while it's nice and stretchy, it's also very lightweight. Meaning you can pretty much see every bump underneath. That's fine with me, but it's something to keep in mind if you're not keen on people seeing all your bra hardware.
Here's another Nettie I made using a thicker stretch knit I bought at Mood Fabrics while I was in NYC (sadly, it's not on the website… and probably not in the store anymore, either, since I bought like 8 yards of it and made everyone else buy some too HA HA HA). It's almost like a thin ponte – and very very soft, with quite a bit of stretch. I LOVE this fabric!
I made the size 4, which I fit pretty squarely in, measurement-wise. If you're looking for something a little less tight, just go up a size or two 🙂 Both of these versions are the scoop front with a high back neckline. I did make a couple with a scoop back neckline, but I've learned that I really don't like the way they look on me, so I'm sticking with high back for now.
As you can see, the thicker fabric results in a smoother look.
To make my Nettie into a tshirt, I just cut the pattern piece about 1″ above the hipline (where the leotard-ness starts). I also added 1.5″ length at the waist, so the shirt would be long enough to cover my waistband. In case you were wondering why I cut length and then re-added it, well, the bottom of the pattern flares out quite a bit to accommodate hips – which I don't need in a tshirt. So I added length at the waist instead.
One of my favorite things (aside from sewing and, you know, people who sew) is making up words. Leotard-ness GOES ON THE LIST!! I think a tshirt Nettie in thin-ish ponte goes on the sewing list, too.
You've totally sold me on this skirt. I wish I had the pattern already, that outfit is pretty much exactly what I want to wear tomorrow!
Yessss, I love making up words too! Im so glad someone agrees with me haha. Also, you totally need that skirt pattern- it would look amaaaazing on you!
Great Netties darling! That stripey ponte needs to be mine. But like, 5 size bigger.
I made the Nettie last night and love it, although unfortunately my fabric doesn't have much vertical stretch – you should try the bodysuit. I can't wear mine until I get some snaps sent though (so I can actually go to the bathroom).
Mood still has the stripe knits. They've just moved them to the other side of the aisle in with the pontes though. Had me in a bit of a panic when I realized I needed more.
I love all your stripes! While I am an utter failure at MMM, I do love seeing how everyone really wears their makes every year!
Looking good! The Nettie shirts look super comfy, I'm keeping it in mind for future shirt projects 🙂 Loving your skirt too!
I'm glad you were able to test the Nettie as a t-shirt. I've been hesitant to buy the pattern because I've never been a fan of bodysuits. Although the dress version did catch my eye. This t-shirt fits you like glove and both versions look amazing. How would you compare it to the Renfrew?
Same! I think my response to Heather when she originally asked me to test started out with me turning her down because I don't like bodysuits, and by the end of the email I'd convinced myself that it would make a great tshirt and yes I'd love to test it. Haha! I'm so glad I tried it because I loooove Nettie as a tshirt (and I'd probably love it as a bodysuit, if I was a bodysuit kinda gal 🙂 Never say never!).
Nice outfits 🙂 Does the Briar in the first photo have a v-neck, or is it just the way you're standing? and if it does…how did you do that?
All my Briars do too..I was wondering if I had somehow missed one of the pattern options, and I'm glad I haven't!


That said, it was hard to have serious discussions of equity and achievement gaps on a campus of a university with a twenty-two billion dollar endowment.
.. Gladwell makes the case that the same size donation would make a much larger social difference at a Rowan than at a Stanford. Having seen both, I have to agree. Wealthy institutions are not immune to the law of diminishing returns.
.. During a long lecture about how they don't lecture, I started playing a variation on "Where's Waldo?," scanning the polaroids for faces of black people. As we passed one of the many glass-walled workspaces, an intense young woman came out to tell us "we'd prefer if you didn't come in." I thought her comment a bit on-the-nose, but there it was.
.. Borrowing a bit from Gladwell, if we assume a five percent return on a 22 billion dollar endowment, that's a little over a billion dollars per year. That's before adding the first dollar of tuition income, any new research support, or new donations. (The guide bragged about their generous financial aid, which sounded impressive until I did the math. Undergrad tuition, fees, room, and board is 68k per year. He mentioned that the typical aid recipient gets about 30k of "scholarship" from Stanford. By my math, that means the typical aid recipient is on the hook for another $38,000 per year.
.. we could go to "free community college" for every student at Brookdale for less than a twentieth of Stanford's annual rentier income.
.. Alternately, its annual rentier income — remember, this is one university — would cover free community college for the entire state of New Jersey, with money left over.
Socioeconomic class has been enveloped and made largely irrelevant while race, gender, and identity have become the totality of what's believed to be "diversity" on campus.


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Villa Comaltitlán est une municipalité du Chiapas, au Mexique. Elle couvre une superficie de  ou  et compte  en 2015.

Histoire

Notes et références

Municipalité au Chiapas
Article dont une information de l'infobox a plusieurs valeurs sourcées

redpajama_set_name: RedPajamaWikipedia


Are you looking for the map of Condom? Find any address on the map of Condom or calculate your itinerary to and from Condom, find all the tourist attractions and Michelin Guide restaurants in Condom. The ViaMichelin map of Condom: get the famous Michelin maps, the result of more than a century of mapping experience.


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Economy and TourismLifestyleNews
Sicily | The Arco Azzurro Jazz Festival ends with Mro Bruno Santori and Giacomo Tantillo
Mediterranean ObserverAugust 7, 20213min745
The fourth edition of the "Arco Azzurro Jazz Festival", will come to end today Saturday 7th August at Arco Azzurro Geosite Bagheria, limits of Palermo, Sicily.
The event is organized by the associations "Natura e Cultura" and "LIPU Bagheria" which manage the Arco Azzurro Geosite, with the patronage of the Municipality of Bagheria.
The artistic director of the festival is the well-known Bagherian trumpet player Giacomo Tantillo who will also take care of the musical organization of the event this year. For the final night, Tantillo, will per participating with his trumpet as there could not be a better conclusion in the incomparable scenery offered by the "Arco Azzurro" area, on the Mongerbino-Aspra coastal road, one of the most evocative landscape views of the Sicilian coast.
Good music lovers, will enjoy what is being called a "Special event", for the final night, themed "Jazz for life", music as a hymn to life and for life. Jazz for life will be interpreted by the "Tantillo Quartet" which includes Giacomo Tantillo (trumpet), Fulvio Buccafusco (bass), David Lo Cascio (drums) and the impeccable Maestro Bruno Santori (piano), conductor, pianist, arranger, composer.
The Tantillo quartet, will be performing timeless jazz music aimed at the general public, including some of the most famous jazz tunes of American tradition.
It would take too long to talk about Maestro Bruno Santori, about the various compositions created, about the shows that saw him as the undisputed protagonist. But we have to mention some of them. Maestro Bruno Santori, for several years was artistic and permanent director of the "Sanremo Festival Orchestra" and currently is the Maestro of the "Mediterranean Orchestra" which was setup through the Mediterranean Tourism Foundation in which he is a Senator. Shifting through the news of his biography we will find a slogan coined by Bruno Santori himself: "Music Unites and elevates Spirituality".
"We wanted to wrap up this aphorism in theming the last concert "Jazz for Life ", said the director Giacomo Tantillo who wanted to conclude this edition by giving the Bagherians an international excellence such as Maestro Santori.
Il Settimanale Di Bagheria
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redpajama_set_name: RedPajamaCommonCrawl


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Tibor Lutter (15 August 1910, Budapest - 9 June 1960, Budapest) was a Hungarian academic and literary scholar.

Life
His parents were János Lutter and Irma Aczél. He started his education in the Jesuit Gymnasium (today: Szent István Gymnasium) in Kalocsa and finished his secondary studies at the II. District Real Gymnasium in Budapest. In 1933, he earned an English-French-Hungarian teacher degree from the Eötvös Loránd University. In 1936, he also earned a Doctor of Philosophy degree in English language at the Eötvös Loránd University.

Teaching career
Between 1933 and 1946, he taught at the IX. District Trade School. Between 1943 and 1944, he also taught at the Deutsche Reichschule in Budapest. Between 1944 and 1945, he also took part in the opposition of the Occupation of Hungary by Nazi Germany.

Between 1946 and 1948, he was a teacher at the University of Szeged. Between 1948 and 1950, he was the director of the Eötvös József College. Between 1946 and 1948, he was a private teacher at the University of Debrecen.

Between 1949 and 1952, he was an instructor at the Department of English of the Faculty of Humanities of Eötvös Loránd University. Between 1949 and 1956, he was an associate professor and a director of the Department of English Language and Literature of the Eötvös Loránd University.

Works
 Lutter, T. (1952). G. B. Shaw. Nep Könyvkiadó, Budapest.
 Lutter, T. (1956). John Milton, az angol polgári forradalom költöje. Akadémiai Kiadó, Budapest.
 Lutter, T. (1959). James Joyce. Gondolat, Budapest.
 András, L.T., Lutter, T., Róna, É., & Károlyné, S. (1963). Rendszeres angol nyelvtan. Tankönyvkiadó Vállalat, Budapest.

References

People from Budapest
1910 births
1960 deaths
Eötvös Loránd University alumni


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Q: validating numeric values in text box I have to allow user to allow only numeric values in the text box . It should remove any non numeric method. No matter how they are supplying the input ...either typing or copy+paste.
My code
var nCheck  = function (field) {
var re = /^[0-9]*$/;
               if (!re.test(field.value)) {

                       field.value = field.value.replace(/[^0-9]*$/g,"");
               }
 };

This works except when you copy paste something like aaa2 . Whereas aaaa or aa work. Problem is when last place contains number it fails .
Thanks for any help.

A: Just do
field.value = field.value.replace(/[^0-9]/g,"");

This will replace everything that's not a number for nothing, and you don't even have to run the test function.

A: The $ means "end of string". Remove it and it should work.
Other tips:
Replace * by +; * includes the empty string
Maybe it should better to warn the user, just in case the numeric character is a typo (like pressing Q instead of 1)

A: If you use jQuery, check out textola a jquery numeric plugin.

A: No regex:
field.value = isNaN(field.value) ? '' : field.value;

redpajama_set_name: RedPajamaStackExchange


as a python programmer and stoner, I feel like a black sheep… glad to know i'm not the only one.
This was hilarious. A clear case of why you shouldn't let coders out of their darkened basements.
I would ban myself from a conference where the attendees light up doobies in public areas.
Dude, you smoked up in a busy place. No matter what you smoked would have been bad enough.
Uh oh – sounds like someone was partying with Bad Decision Dinosaur!
Don't take this the wrong way but 95% of what you said in the last hour was not funny. It wasn't "humor on the edge of acceptability", it just wasn't funny.
I don't want to come across as having any animosity… You go to the TiP BoF, you take your chances. You just said your memory was hazy so I thought I'd give you a reality check.
As far as your point about drinking going on in there (and this is not at all an official PyCon response): Drinking in that room is not, as far as I know, illegal. I don't think it's even against facility policies. I believe the issue is bringing in outside alcohol, without paying the corkage fees, and possibly without having a "bartender" to limit the consumption by minors or those who are already too enthusiastic.
Was your banning justified? I wouldn't say it was justified so much as inevitable. Apparently several people complained of illegal activity to PyCon organizers, and the organizers had to take action. I don't know if you feel this was unjustified, but if so realize that the organizers had little choice in response and they selected pretty much the lightest response possible.
Small clarification, I did say "outside alcohol" in the post, and the conference hotel had (I overheard in casual conversation so could be lacking details) asked the conference to stop that previously.
"…and will not be allowed to attend PyCon US in 2014 or 2015." — good news! It seems you can choose which year you stay away.
Smoking and inebriation at a technical conference aren't cool. But neither is having a multi-page code of conduct written by feminists and enforced by conference goons. I think PyCon has jumped the shark.
Any kind of smoke travels and becomes an issue for everyone in the room. Smoke that's illegal in the state for recreational purposes is even more so. That was a bad decision. What does it mean for people like you? Maybe that you should do more thinking and leave your stash in your hotel room if not at home.


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Oferta dla wydawnictw
Biuletyn Telegram
Czytelnia Medyczna » New Medicine » 4/2009 » Hyperglycaemia in Acute Coronary Syndrome: an unsolved problem in clinical medicine
Zastanawiasz się, jak wydać pracę doktorską, habilitacyjną lub monografie? Chcesz dokonać zmian w stylistyce i interpunkcji tekstu naukowego? Nic prostszego! Zaufaj Wydawnictwu Borgis - wydawcy renomowanych książek i czasopism medycznych. Zapewniamy przede wszystkim profesjonalne wsparcie w przygotowaniu pracy, opracowanie dokumentacji oraz druk pracy doktorskiej, magisterskiej, habilitacyjnej. Dzięki nam nie będziesz musiał zajmować się projektowaniem okładki oraz typografią książki.
Zamów prenumeratę czasopisma!
© Borgis - New Medicine 4/2009, s. 109-113
*Calin Pop1, Marcel Pop2, Lavinia Pop1
Hyperglycaemia in Acute Coronary Syndrome: an unsolved problem in clinical medicine
1 "Vasile Goldis" Vest University, Faculty of Medicine, Arad, Romania
Head: Prof. Aurel Ardelean, rector
2 Semmelweis University, Faculty of Health Science, Budapest, Hungary
Head: Prof. Judit Meszaros, PhD
Acute or stress hyperglycaemia represents the transient elevation of the blood glucose level due to the activation of neurohormonal mechanisms in organisms exposed to stress. An abnormal prevalence of glycosuria in patients with acute coronary syndrome (ACS) had been reported as early as 1931 but it was only in 1975 that an abnormally high level of glycaemia following acute myocardial infarction (AMI) was noted to represent an aggravating factor affecting prognosis.
Acute hyperglycaemia induced hazards regarding ACS prognosis can be explained by the prevalence of insulin resistance syndrome in these patients, irrespective of the presence or absence of diabetes mellitus (DM), while clinical trials clearly highlight the fact that intensive glycaemic control reduces mortality rate in patients with a critical state of different illnesses, lessens the deterioration of renal function and cuts cardiovascular risk in patients with ACS. Glycaemic control in hyperglycaemia patients with ACS can be carried out by using a metabolic mixture containing a glucose-insulin-potassium mixture (GIK) independent of the glucose level status, or better by optimized insulin therapy. Proper achievement of the standardized protocol is imperative for obtaining optimal glycaemic levels and minimizing hypoglycaemia risks, especially in patients who develop ACS. Ongoing studies and trials will provide new elements and information that will improve the evolution and prognosis of patients with ACS and hyperglycaemia.
Key words: acute hyperglycaemia, acute coronary syndrome, tight glycaemic control, cardiovascular risk.
Acute or stress hyperglycaemia represents the transient elevation of the blood glucose level due to the activation of neurohormonal mechanisms in organisms exposed to stress.
The first data about the presence of hyperglycaemia in patients with critical illnesses were described by Claude Bernard in 1855. Since then a number of studies have demonstrated that in 5-30% of the cases these illnesses are accompanied by stress hyperglycaemia (1, 2).
Acute hyperglycaemia also induces imminent hazards regarding the evolution and prognosis of patients developing acute coronary syndrome (ACS), partially explainable by the increased prevalence of insulin resistance syndrome (3).
For better medical practice in this exciting field it is imperative that answers be found to a number of questions related to:
1. The prevalence and the risks induced by acute hyperglycaemia in ACS.
2. Whether elevated blood glucose is a marker or a mediator of more severe myocardial damage.
3. Whether acute treatment is going to have a significant impact or not; whether it can reduce short-term or long-term mortality and morbidity rate following ACS.
Prevalence and risks associated with acute hyperglycaemia in ACS
An abnormal prevalence of glycosuria in patients with ACS was reported as early as 1931, but it was only in 1975 that attention was directed to abnormally high glycaemia following acute myocardial infarction (AMI) representing an aggravating factor for prognosis (4, 5).
The influence of hyperglycaemia in patients free from diabetes mellitus
The first meta-analysis regarding the topic was published in 2000 by Capes et al. It comprised 15 cohort studies and clinical trials gathering 1856 patients free from DM, hospitalized for AMI. The relative risk (RR) of mortality was 3.9 times higher in patients with glucose>110 mg/dl (95% confidence interval [CI]:2.5-5.4) while in patients with glucose>144 mg/dl cardiogenic shock and congestive heart failure (CHF) it had a high prevalence. In their subsequent studies Wahab (6), Stranders (7) and Meier (8) successively demonstrated the existence of a larger necrotic area and a 4% higher mortality rate for each 18 mg/dl increase of glucose level in patients with AMI and admission hyperglycaemia, independent of the prior presence or absence of DM. In 2005 Ainla et al. (9) presented a study on 775 hospitalized patients with AMI in whom the mortality rate was 4 times higher in the subgroup with glucose level ≥ 200 mg/dl, 47% vs. 14%, compared with normoglycaemic patients. The Cooperative Cardiovascular Project (CCP), the most comprehensive study yet, evaluated 141,680 patients with AMI, and highlighted that depending on the admission glucose level (≥ 100 mg/dl up to ≥ 240 mg/dl) cardiovascular mortality rate increased from 13 to 77% at 30 days and 7 to 46% at 1 year.(10) Mortality risk was not influenced by the presence or absence of DM, but in patients with the same blood glucose level and free from DM the mortality rate showed a linear increase with glucose level ≥ 110 mg/dl. Mortality risk and CHF showed similar results starting with glucose level ≥ 200 mg/dl, irrespective of the diabetes status (11).
The influence of hyperglycaemia in patients with diabetes mellitus
The prevalence of DM in patients hospitalized for ACS is 20-25% but acute hyperglycaemia occurrence is more frequent and is present in 50% of them, even in those without a history of diabetes (3, 4, 6, 12, 13).
Isihara et al. (14) monitored 1,253 patients with AMI and DM who underwent emergency angioplasty (PTCA) and in whom the mortality rate was significantly higher (10% vs. 5%) as well as the procedural complications, having glucose level ≥ 200 mg/dl.
In a subsequent study Cao et al. (15) pointed out that mortality risk was 5 times higher in patients with blood glucose level ≥ 300 mg/dl and 2.6 times higher in those with blood glucose level ≥ 218 mg/dl, compared with blood glucose level ≥ 160 mg/dl, the reference value in the study.
DIGAMI [Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (16)] clinical trials CREATE–ECLA [Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment (17)] and HI-5 [Hyperglycemia Intensive Insulin Study in Infarction (18)] also highlighted a higher mortality rate (14-26%) in the long run in patients with AMI and DM.
The trials and the studies conducted so far suggest a different impact for acute hyperglycaemia in patients with ACS, depending on the presence or absence of DM. Thus some patients with hyperglycaemia but free from known DM could well have had an unidentified diabetes status, forming an extremely high risk group. It is also possible that a higher grade of severity of the disease or a higher level of stress resulted in the same level of hyperglycaemia in patients free from DM, although there is a tendency to administer intensive treatment to patients with hyperglycaemia and known DM.
Definition of admission hyperglycaemia
Hospital admission hyperglycaemia target values differ according to different studies. Moreover, there is no consensus about the definition of abnormal blood glucose values, methods to monitor blood glucose levels, the benefits of treatment, and the target values for blood glucose. A recent clarification on the subject matter has been issued by Deedwania et al. (19), who, irrespective of the metabolic status of patients developing ACS, suggest for hyperglycaemia an admission plasmatic glucose level ≥ 140 mg/dl, while for severe hyperglycaemia with a very high risk of poor outcome a value of ≥ 180 mg/dl is considered the lower limit. It is highly recommended to test plasma glucose levels compared to capillary glucose levels as plasma glucose levels tend to show 10% higher values (20).
Cardiovascular effects of acute hyperglycaemia in patients with ACS
In different studies hyperglycaemia was associated with a high incidence of coronary artery occlusions, with an unsatisfactory reestablishment of coronary artery blood flow type TIMI 0-2 [OR=2.6091.50-4.50)] and the occurrence and persistence of the so-called "no-reflow" phenomenon (21,22). Iwakura et al. published the results of a study carried out on 146 patients with AMI who underwent PTCA and among whom 52% of those having blood glucose level ≥ 160 mg/dl frequently suffered from the "no-reflow" phenomenon vs. 14% of normoglycaemic subjects. Isihara et al. (14) described a similar situation with a more frequent incidence of the "no-reflow" phenomenon in hyperglycaemic patients, 17% vs. 9%, as well as in those with known DM, 26% vs. 12%, whose blood glucose level was ≥ 200 mg/dl. In the same study hyperglycaemia was associated with more reduced values of ejection fraction (EF), 51% vs. 56%, associated with a delay of the reestablishment of contractile function, evaluated by the "Wall Motion Score Index" (delta WMS) in the study reported by Iwakura et al. (23). The afore-mentioned correlations are extremely important as the "no-reflow" phenomenon has been associated with a significant increase of mortality rate, while EF value is an important marker of long-term prognosis in patients with AMI (8, 24).
Acute hyperglycaemia determines endothelial dysfunction and inflammatory phenomena as a result of vasoconstriction. There is a prothrombotic state facilitated by the modification of plaquetary function and diminished fibrinolysis associated with the pro-inflammatory state induced by activation of κβ transcriptional intranuclear factor and metalloproteinase accumulation and the PAI-1 plasminogen activator inhibitor factor, favouring fissure and rupture of the atherosclerotic plaque. Insulin deficiency and excessive catecholamine release reduce ischaemic myocardium glucose utilization promoting glycogenosis with the stimulation of lipolysis and the increase in circulation of free fatty acids having pro-arrhythmogenic effects. Hyperglycaemia had formerly been associated with apoptosis and the reduction of collateral blood flow, the increase in necrotic area and the abolition of ischaemic preconditioning, associated with QT interval prolongation and a remarkable increase in arterial pressure in human volunteers with>270 mg/dl induced glucose level (25-32).
The relationship between all these physiopathological mechanisms seem to be ensured by the insulin-resistance phenomenon which in the SAN ANTONIO Heart Trial was associated with a 2.5 increase of mortality rate and major cardiovascular events even after multivariable analysis adjustment for the main cardiovascular risk factors (33).
The role and benefits of intensive hyperglycaemia management in ACS
Glycaemic control in hyperglycaemic patients with ACS can be carried out in two ways: by using a metabolic mixture containing a glucose-insulin-potassium mixture (GIK) irrespective of the blood glucose level, or by the optimized administration of insulin exclusively in patients with acute hyperglycaemia.
The concept of administering GIK has been based on the study carried out by the Sodi–Pallares team, who suggested that the GIK infusion could protect the ischaemic myocardium by reducing the oxidized free fatty acids and by ameliorating metabolic glucose utilization (34). This was followed by the CREATE–ECLA randomized trial conducted on 20,201 patients with AMI – the trial did not demonstrate any beneficial effect of GIK, thus tempering any kind of former enthusiasm about the idea. The results showed an increase in the blood glucose level of the respective patients during the first 6 hours after administration, a decrease in the placebo group and an especially high mortality rate, 14% vs. 6% in the group of patients with high blood glucose level when compared with the normal level (17).
In contrast with GIK administration in different studies and trials the normalization of the blood glucose level after intravenous administration of insulin, critical status patients´ prognosis was found to ameliorate. This was a reference trial conducted by Berghe et al. (35) on a batch of 1,548 patients with critical post-surgery status. These patients were exposed to 80–110 mg/dl tight glycaemic control through a pseudo-physiological intensive insulin therapy (basal–bolus). In the active batch the intensive care unit in-hospital mortality rate decreased significantly from 8% to 4.6% and from 10.9% to 7.2% throughout the entire period of hospitalization.
The aforementioned results cannot be extrapolated in a simple way to ACS patients, and 3 clinical trials have tested the way in which tight glycaemic control through insulin therapy significantly reduces the mortality rate and in-hospital complications in hyperglycaemic patients with ACS (16, 18, 36).
The DIGAMI study was the first and most important to monitor the effects of intensive insulin therapy (a continuous infusion followed by multi-dose subcutaneous administration) versus the standard treatment, in 620 patients with AMI and known type II DM and/or>200 mg/dl admission blood glucose level (16). The glycaemic control was superior in the intensive treatment batch, 173 mg/dl vs. 210 mg/dl, and was associated with a significant decrease of mortality rate in the respective group; one-year mortality was 19% vs. 26% and the follow-up was extended to 3.4 years. The respective trial continues to be the only one in the field which has succeeded in reducing blood glucose level significantly and which demonstrated that accurate tight glycaemic control is correlated with a better prognosis for survival in hyperglycaemic patients with ACS.
The DIGAMI-2 trial directed the study towards three ways of insulin therapy (a 24-hour continuous infusion treatment followed by a ≥ 3 months intensive multi-dose regimen therapy, a 24-hour continuous infusion treatment followed by conventional regimen, and the conventional insulin regimen) – on a batch of 1,253 randomized patients with AMI and known type II DM and/or>200 mg/dl admission blood glucose level (36). The study evidenced no difference in survival among the 3 groups, explainable by the fact that the goal of long-term glycaemic control in the intensive treatment group (90-126 mg/dl) has never been achieved. A similarity between the two DIGAMI studies was that patients with DM were included, none of them with acute hyperglycaemia free from DM, who in fact represented the highest mortality AMI risk group associated with hyperglycaemia.
The HI-5 trial tried to find a solution to some questions of the DIGAMI study and was the first randomized trial which included patients with hyperglycaemia and unknown diabetes status: included in the study were 244 patients with AMI and type II DM or with>140 mg/dl blood glucose level, who received either a 24-hour intensive insulin infusion treatment or the standard insulin infusion in order to achieve a blood glucose level of 72–180 mg/dl. The trial did not highlight any difference regarding the mortality rate between the two groups, raising the same issues as the DIGAMI–2 study (comparison was made between two insulin regimens, instead of two different intensity variants of glycaemic control); no significant difference was registered regarding blood glucose level median values between the intensive group and the one receiving the standard therapy (18).
As hyperglycaemia had direct detrimental effects on patients, significantly aggravating their prognosis after ACS, further important clarification is necessary: 1) How should hyperglycaemia be treated and what are the goals of the therapy in patients free from DM and those with known DM? 2) What is the period of vulnerability to hyperglycaemia in patients with ACS? and 3) What is the impact of persistent in-hospital hyperglycaemia?
Prognostic value of hypoglycaemia
An important aspect deriving from intensive glycaemic control in patients with ACS is the possibility of occurrence of hypoglycaemia, an important predictor of adverse events. In the Svensson et al. (37) study, <54 mg/dl blood glucose level was associated with an increased mortality rate by 93%. In another study admission hypoglycaemia was correlated with cardiovascular mortality and a high incidence of 30-day reinfarction, in some way related to hyperglycaemia, but it is not clear whether the detrimental effect of hypoglycaemia impact was related to all hypoglycaemic events or was restricted only to the clinically severe ones (38).
The necessity of implementing a standard insulin therapy protocol
Attempts to elaborate a standard insulin therapy protocol in patients with ACS and hyperglycaemia have failed due to the lack of a consensus. The information concerning hyperglycaemia management in patients with ACS is still limited and the existing studies have highlighted the fact that 78% of patients free of DM and 27% of those with DM have not been administered insulin therapy in case of blood glucose level values>240 mg/dl (10). Inzouchi et al. propose an in-hospital management algorithm for hyperglycaemia in patients with critical status, but implementation of it in patients with ACS has been limited by cardiologists´ fear that hypoglycaemic episodes could appear, as the number of qualified personnel who should monitor hyperglycaemic status is reduced and because of the absence of trials which could clearly demonstrate the necessity to achieve normoglycaemic status in these patients.
Current guidelines
The most comprehensive guidelines were issued by the AHA Diabetes Committee in 2008 and were presented under the title: Scientific Statement – Hyperglycemia and Acute Coronary Syndromes. These guidelines are based on the premise that no matter how intense and documented, the interdependence between hyperglycaemia and ACS requires further investigation (19)
Namely:
– In-hospital blood glucose level should be checked in all patients with suspected or confirmed ACS as part of the initial laboratory investigation [Evidence Level A].
– Suspected or confirmed ACS patients admitted to intensive care units for coronary heart disease must undergo tight glycaemic control [Evidence Level B].
– Intensive insulin therapy is recommended for patients whose blood glucose level is ≥180 mg/dl [Evidence Level B], and it is beneficial to keep it within 90-140 mg/dl [Evidence Level C].
– Special attention should be given to patients who are not admitted to intensive care units, with subcutaneous insulin therapy in order to keep their blood glucose level <180 mg/dl [Evidence Level C].
– The efficiency and applicability of insulin therapy is generally recognized in ACS patients, but until a new standardized protocol is developed, efforts should be made for the secure implementation of the existing one, to minimize the risks for hypoglycaemia. [Evidence Level B].
– Hyperglycaemic patients without known DM should be evaluated for the severity of metabolic disturbances [Evidence Level B].
– On leaving the hospital, all hyperglycaemic patients with or without DM should be scheduled for a follow-up metabolic control therapy [Evidence Level C].
Acute hyperglycaemia aggravates the evolution and the prognosis of ACS patients, irrespective of their diabetic status. The clinical trials carried out so far have demonstrated the fact that intensive glycaemic control decreases the mortality rate in patients with critical status illness; it decreases the deterioration of renal function and indicates a reduction in risk for cardiovascular events in patients with ACS. The elaboration of a standardized protocol is imperative to rapidly achieve optimal levels of glycaemia and to minimize hypoglycaemia risks. Ongoing studies and trials will bring new elements and information regarding the benefits and therapeutic options for hyperglycaemia in ACS.
1. Bernard C. Lecons de physiologie experimentale appliqué a la medicine.Vol I.Balliere, Paris, 1855: 296-313. 2. Mc Kowen K, Malhotra A, Bistrian BR. Stress induced hyperglycemia. Crit Care Clin 2001; 17: 107-124. 3. Capes S, Hunt D, Malmberg K, et al. Stress hyperglycemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic owerview. Lancet 2000; 335: 773-778. 4. Cruikshank N.Coronary thrombosis and myocardial infarction with glycosuria. BMJ 1931; 1:618-619. 5. Ravid M, Berkowicz M, Sohar E. Hyperglycemia during acute myocardial infarction: a six – year follow –up study. JAMA 1975; 233: 807-809. 6. Wahab NN, Cowden EA, Pearce NJ, Gardner MJ, Merry H, Cox JL. ICONS Investigators. Is blood glucose a independent predictor of mortality in acute myocardial infarction in thrombolytic era? J. Am. Coll Cardiol.2002; 40: 1748-1754. 7. Stranders I, Diamant M, van Gelder RE, Spruijt HG, Twisk Jw, Heine RJ, Visser FC. Admission blood glucose blod glucose level as risk indicator of death after myocardial infarction in patients with and without diabetes mellitus. Arch Intern Med 2004; 164: 982-988. 8. Meier JJ, Deifuss S, Klamann A,Launhardt V, Schmiegel WH, Nauck MA. Plasma glucose at hospital admission and previous metabolic control determine myocardial infarct size and survival in patients with and without type 2 diabetes: the Langendreer Myocardial Infarction in Diabetic Patients Assesment (LAMBDA). Diabetes Care 2005; 28: 2551-2553. 9. Ainla T, Baburin A, Teesalu R, Rahu M. The association between hyperglycemia on admission and 180-day mortality in acute myocardial infarction patients with and without diabetes.Diabet Med 2005; 22: 1321-1325. 10. Kosiborod M, Rathore SS, Inzucchi SE, Masoudi FA, Wang I, Havranek EP, Krumholz HM. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulations 2005; 111: 3078-3086. 11. Zeller M, Steg P, Ravisy J, Laurent Y, Janin-Manificant L, L&acuteHuillier I, Beer J, Oudot A, Rioufol G, Makki H, Farnier M, Rochette L, Cottin Y.Prevalence and impact of metabolic syndrome on hospital outcome in acute mzocardial infarction. Arch Intern Med 2005; 165: 1192-1198. 12. Norhammar A, Tenerz A, Nilsson G, Hansten A, Efendic S, Ryden L, Malmberg K. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet 2002; 359: 2140-2144. 13. Malmberg K, Norhammar A, Wedel H, Ryden L. Glycometabolic state at admission: Important risk factor of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction:long term results from the Diabetes and Insulin – Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation 1999; 99: 2626-2632. 14. Ishihara M, Kojima S, Sakamoto T. Acute hyperglycemia is associated with adverse outcome after myocardial infarction in the coronary intervention era. Am Heart J 2005; 814-820. 15. Cao JJ, Hudson M, Jankowski M, Whitehouse F, Weaver VD. Relation of acute and chronic glycemic control on mortality in acute myocardial infarction with diabetes mellitus. Am J Cardiol 2005; 96:183-186. 16. Malmberg K. DIGAMI (Diabetus Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. Prospective randomised study of insulin intensive treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ 1997; 314: 1512-1515. 17. Mehta SR, Yusuf S, Diaz R, Zhu J, Pais P, Xavier D, Paolasso E, Ahmed R,Xie C, Cazni K, Tai J, Orlandini A, Pogue J, Liu L. CREATE – ECLA Trial group. Effect of glucose-insulin-potassium infusion in patients with acute ST-elevation myocardial infarction: the CREATE – ECLA randomized trial. JAMA 2005;293:437-446. 18. Cheung NW, Wong WV, McLean M. The Hyperglycemia: Intensive insulin infusion in infarction (HI-5) study: a randomized controlled trial of insulin infusion therapy for myocardial infarction.Diabetes Care 2006; 29: 765-770. 19. Deedwania P, Kosiborod M, Barett E, Cerriello A, Isley W, Mazzone T, Raskin P. Hyperglycemia and Acute Coronary Syndrome.Circulation 2008;117:160-1619. 20. Goldberg PA, Bozzo JE, Thomas PG, Mesmer MM, Sakhorova OM, Radford MJ, Inzucchi SE. "Glucometrics": assessing the quality of inpatient glucose management. Diabetes Technol Ter 2006; 8: 560-569. 21. Timmer JR, Ottervanger JP, DE Boer MJ,van der Horst IC. Hyperglycemia is an important predictor of impaired coronary flow before reperfusion therapy in ST-segment elevation myocardial infarction.J Am Coll Cardiol 2005; 45: 999-1002. 22. Stone GW, Cox D, Garcia E. Normal flow (TIMI -3) before mechanical reperfusion therapy is an independent survival in acute myocardial infarction: analysis from the primary angioplasty in myocardial infarction trials. Circulation; 104:636-641. 23. Iwakura K, Ito H, Ikushima M. Association between hyperglycemia and the no-reflow phenomenon in patients with acute myocardial infarction.J Am Coll Cardiol 2003; 41:1-7. 24. Brodie BR, Stuckey TD, Wall TC. Importance of time to reperfusion for 3-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction J Am Coll Cardiol 1998; 32: 1312-1319. 25. Kawano H, Motoyama T, Hirashima Q, Hirai N, Miyao Y, Sakamoto T, Kugiyama K, Ogawa H, Yasue H. Hyperglycemia rapidly supress flow mediated endotheluim dependent vasodilatation of brachial artery. J Am Coll Cardiol 1999; 34: 146-154. 26. Ceriello A. Acute hyperglycemia: a new risk factor during myocardial infarction. Eur Heart J 2005; 26: 328-331. 27. Young LH, Renfu Y, Russel R, Hu X, Caplan M, Ren J, Shulmann GI, Sinusas AJ. Low –flow ischemia leads to translocation of canine heart GLUT – 4 and GLUT-1 glucose transporters to the sarcolemna in vivo.Circulation 1997; 95: 415-422. 28. Kersten JR, Toller WG, Tesmer JP, Pagel PS, Warltier DC. Hyperglycemia reduces coronary collateral blood flow through a nitric oxid mediated mechanism. Am J Physiol Heart Circ Physiol 2001; 281: H2097-H2104. 29. Kersten JR, Schemeling TJ, Orth KG, Pagel PS, Warltier DC. Acute hyperglycemia abolishes ischemic preconditioning in vivo. Am J Physiol 1998; 275(pt2): H721-H725. 30. Ceriello A, Quagliaro L, D&acuteAmico M, Di Filippo C, Marfella R, Nappo F, Berrino L, Rossi F, Giugliano D. Acute hyperglycemia induces nitrotyrosine formation and apoptosis in perfused heart from rat. Diabetes 2002; 51: 1076-1082. 31. Marfella R, Nappo F, De Angelis L, Siniscalchi M, Rossi F, Giugliano D. The effect of acute hyperglycemia on QTc duration in healthy man. Diabetologia 2000; 43: 571-575. 32. Aljada A, Friedman J, Ghanim M, Mohanty P, HofmeyerD, Chaudhuri A, Dandona P.Glucose ingestion induces an increase in intranuclear factor kappa B, a fall in celullar inhibitor kappa B, and an increase in tumor necrosis factor alpha messenger RNA bz mononuclear cells in healthy human subjects. Metabolism 2006; 55: 1177-1185. 33. Hanley AJ, Williams K, Stern MP, Haffner SM. Homeostasis model assessment of insulin resistance in relation to the incidence of cardiovascular disease: the San Antonio Heart Study. Diabetes Care 2002; 25:1177-1184. 34. Sodi-Pallares D, Testelli MR, Fishhelder BL, Bisteni A, Medrano GA, Friedland C, DeMichelli A. Effects of a intravenous infusion of a potassium -glucose-insulin solution on the electrocardiographic signs of myocardial infarction: a preliminary clinical report. Am J Cardiol 1962; 9: 166-181. 35. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruynincks F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically in the ill patients. N Engl J Med 2001; 345: 1359-1367. 36. Malmberg K, Ryden L, Webel H, Birkeland K, Bootsma A, Dickstein K, Efendic S, Fisher M, Hamstem A, Herlitz J, Hildebrant P, Mac Leod K, Laakso M, Torp-Pedersen C, Waldenstrom A. Digami – 2 Investigators. Intensive metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction: effects on mortality and morbidity. Eur Heart J 2005; 26: 650-661. 37. Svensson AM, Mc Guire DK, Abrahamsson P, Delborg M. Association between hyper- and hypoglycaemia and two year all- cause mortality risk in diabetic patients with acute coronary events. Eur Heart J 2005; 26: 1255-1261. 38. Kadri Z, Danchin N, Vaur L, Cottin Y, Gueret P, Zeller M, Lablanche JM, Blanchard D, Hanania G, Genes N, Cambou JP: USIC 2000 investigators. Major impact of admission glycemia on 30 day and one year mortality in non diabetic patients admitted for myocardial infarction: results from the nationwide French USIC 200O study. Heart 2006; 92: 910-915. 39. Inzucchi S. Management of hyperglycemia in the hospital setting. N Engl J Med 2006; 155: 1903-1911.
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Q: Integral - different from $0$? I want to find $\int_0^{2\pi} \frac{1}{1+\sin(x)cos(x)}dx$. This function is always $>0$ so its integral from $0$ to $2\pi$ should be different from $0$. But when i found the indefinite integral, I got $\frac{2}{\sqrt{3}}\arctan(\frac{2\tan + 1}{\sqrt{3}})$, which gives the same result for $x=2\pi$ and for $x=0$, so my integral is equal to $0$. Can somebody help me find a mistake in my way of thinking?

A: We have the integrand as
$$\dfrac1{1+\dfrac{\sin(2x)}2} = \sum_{k=0}^{\infty} (-1)^k \dfrac{\sin^k(2x)}{2^k}$$ Now use the technique mentioned here to get what you want.

A: To apply the fundamental theorem of calculus, the primitive must be a differentiable function on $[0,2\pi]$. But it's not even defined at $\pi/2$.

A: This integral can be done using complex variables. Put $z=e^{ix}$ to get
$$\int_0^{2\pi} \frac{1}{1+\sin(x)\cos(x)} dx =
\int_{|z|=1} \frac{1}{iz} \frac{1}{1+1/(4i)(z-1/z)(z+1/z)} dz \\=
\int_{|z|=1} \frac{1}{iz} \frac{4iz^2}{4iz^2+(z^2-1)(z^2+1)} dz =
\int_{|z|=1} \frac{4z}{4iz^2+(z^2-1)(z^2+1)} dz.$$
Using e.g. the quadratic formula we see that the four poles of the integrand are given by
$$z_{0,1,2,3} =\pm \sqrt{\pm i\sqrt{3}-2i}.$$
Of these, only $z_{0,1}$ are inside the unit circle:
$$z_{0,1} = \pm \sqrt{i\sqrt{3}-2i}.$$
The residues $w_{0,1}$ at these poles are given by
$$w_{0,1} = \lim_{z\to z_{0,1}} \frac{4z}{8iz+4z^3}
=\lim_{z\to z_{0,1}} \frac{1}{2i+z^2} =
\frac{1}{2i+i\sqrt{3}-2i} = -i\frac{\sqrt{3}}{3}.$$
It follows that the value of the integral is
$$2\pi i \times 2 \times -i\frac{\sqrt{3}}{3} = \frac{4\pi\sqrt{3}}{3}.$$

A: @Anne : your integrand is positive so your answer must be positive.  If you use $\sin(x)\cos(x)=\frac{1}{2}\sin(2x)$, use the substitution $y = 2x$, and use the $2\pi$-periodicity of $\sin$, eventually you get something like $2\int_{-\pi}^\pi \frac{1}{2+\sin(y)}\,dy$.  By the symmetry of $\sin$, this can be further simplified to  $4\int_{-\pi/2}^{\pi/2} \frac{1}{2+\sin(y)}\,dy$.  You can find the antiderivative using the "Weierstrass substitution" (http://en.wikipedia.org/wiki/Weierstrass_substitution, and it has probably been discussed here ad nauseum)  but based on your question, it appears that maybe you already know how to do it.  Maple gives me
$\frac{2\sqrt{3}}{3}\tan^{-1}(\frac{1}{\sqrt{3}}(2\tan(\frac{y}{2})+1))$ for the antiderivative. This is well-defined when $y = \pm \frac{\pi}{2}$.
The indefinite integral you originally got is clearly wrong because it is periodic, which is impossible because your integrand is always positive. This is the case even if there is a way to deal with the singularities where $\tan(x)$ is undefined.  I don't know exactly what went wrong without seeing how you got it, but remember that $\tan(\theta) = s$ does not always imply $\theta = \tan^{-1}(s)$.


RISMedia's REAL ESTATE April 2019 51 In our recent Voice of the Real Es- tate Agent Report, over 1,000 real estate professionals from around the U.S. shared insights on the big - gest opportunities for growth in the next year. Specifically, we looked at how these opportunities translate into earnings. Responses to the survey show that the top opportunities to earn more this year focus on three key areas: 1. BUILD A STRONG REFERRAL NETWORK Fifty-six percent of respondents said that referral growth is the most sure - fire way for agents to realize profit- able gains in their business this year. More than 92 percent of top- performing agents in the study at - tribute their professional success to their strong referral base. These top performers gain most of their busi - ness from repeat clients. Where does that leave those who don't yet have a portfolio built to rely on repeat business? Two op - portunities rise to the top: commu- nity involvement and growing your local market knowledge. Those who climbed to top-performing sta - tus grow their referral base through community efforts. They engage in volunteer opportunities and network in both professional and community venues. They cultivate referrals by working side-by-side with neighbors. The second key to growing your client referral base is growing your local market expertise. Focus on becoming the go-to resource in the community by publishing blogs, vid - eos and social media posts that truly help others. 2. EMBRACE DIGITAL MARKET- ING AND SOCIAL MEDIA Thirty-two percent of agents recom- mend increasing online marketing to grow your business. Across every segment measured, agents unani - mously warn against ignoring online marketing and social media opportu - nities. Some responses cross over into a broader concern for the profes - sion's ability to keep up with evolving technology. Most agents shared that they don't embrace digital and social media marketing because they don't have time to invest in the area, they don't know where to start, or they simply prefer to not have a digital presence. If you're not skilled in this area, you can build a mentor relationship or enroll in continuing education and professional development courses to help you gain the skills and com - fort you need in this space. 3. MANAGE YOUR TIME Twelve percent of agents indi- cate that time management is the most important aspect of earning more this year. Sometimes that's easier said than done given the competing priorities in the day and the life of an agent. Respondents who are successful in owning their time rely on several habits, including building out their team, automation and taking a "whole lifestyle ap - proach" to their time, which means they plan their real estate schedule into their lifestyle versus the other way around. You can download the full Voice of the Real Estate Agent Report at realestateexpress.com/agent- insights. The report shares tips and best practices from real estate professionals spanning all markets and specializations. RE Alexis Petersen is the director of content at Real Estate Express, the national leader in online learning for pre-licensing, continuing education and professional development. For the last six years, she has been educating real estate professionals on how to successfully launch and advance their career. She's also a seasoned marketing veteran, with nearly 15 years of experience. To learn more, visit www.RealEstateExpress.com. 3 Keys to Successfully Scaling Your Real Estate Business Commentary by Alexis Petersen I f you're looking to scale your real estate business this year, you may find some comfort in knowing that you're not alone.


Surgical drains are used in abdominoplasty patients to combat wound closure disruption by hematoma or seroma formation. Several recent publications have described techniques that allow abdominoplasty to be performed safely without the need for surgical drains. This has not, however, been described in the case of the bariatric patient, who is often considered to be of higher postoperative complication risk. Here, we describe our experience of the drainless abdominoplasty in patients who have undergone massive weight loss (MWL) after a bariatric procedure.
A retrospective review was conducted of 172 patients who had undergone drainless abdominoplasty using the progressive tension suture technique from 2011 to 2014. Thirty-five patients who had undergone MWL after bariatric surgery were assigned to group A. One hundred thirty-seven patients who had not undergone MWL with no history of bariatric surgery were assigned to group B. Demographics, intraoperative outcomes, and postoperative outcomes were compared.
Patients in group A were older (mean age, 48.7 vs 42.7 years; P = 0.003) and had a higher body mass index (26.6 vs 24.6 kg/m2, P = 0.01), a significantly larger tissue resection (2379 vs 1228 g, P = 0.0001), and a higher estimated blood loss (100 vs 120 mL, P = 0.049). There was also a significant group-to-group difference in the American Society of Anesthesiologists Physical Status Classification distribution, with a higher percentage of MWL patients having higher scores. Despite these differences, group A did not have a statistically higher incidence of complications. There was no statistically significant difference in the rate of seroma formation (11% vs 2%, P = 0.055), wound infection (2.9% vs 4.4%, P = 0.68), wound dehiscence (8.6% vs 8.0%, P = 0.91), meralgia paresthetica (2.8% vs 1.5%, P = 0.51), or rate of reoperation (11.4% vs 13.9%, P = 0.7) between the 2 groups.
Despite post–bariatric surgery patients being considered higher risk for postoperative complications, drainless abdominoplasty can be safely offered to this population by using a progressive tension suture technique.


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Exeter combines high-tech treatment with old fashioned care
Karen Dandurantnews@seacoastonline.com
EXETER — In addition to their own highly skilled staff, the Exeter Hospital Center for Cancer Care team includes Massachusetts General Hospital Cancer Center physicians and nurse practitioners who offer state of the art cancer treatment here in the local community.
Dr. Diane Palladino, a breast surgeon with Core Physicians, works closely with the oncology doctors and the high-risk breast cancer screening program. She said the multidisciplinary team approach at Exeter makes their treatment easier on the patient, while providing excellent care.
"We evaluate patients closely for the risk of developing breast cancer, as part of their general breast health exams," said Palladino. "We interview them and take a very detailed family history, menstrual history and do a physical exam. We review any imaging tests they have had."
Palladino said Exeter surgeons are members of the American Society of Breast Surgeons.
"That allows us to use their computer model to plug in all the data," said Palladino. "We can put in past biopsies. We plug in their BRCA risk factor and if they are of Ashkenazi Jewish descent, a high risk for the BRCA2 gene. We get back four or five risk assessments, like a five-year risk, or a lifetime risk of getting cancer."
That data allows doctors to create an action plan for each individual patient.
"Should they have testing done? Should we make a follow up plan?" said Palladino. "Should the patient have yearly mammograms or an MRI? Do we want to test for the BRCA gene? Another option is to place the patient on a chemo prevention drug."
Cancer loves estrogen. Palladino said the chemo is intended to lower estrogen. If used, the patient would also be counseled on lifestyle preventative choices, like exercise, a low fat diet and avoiding hormone replacement therapies.
"Estrogen is made in the ovaries but also in fat tissue," said Palladino. "So, decreasing estrogen lowers the risk. New mothers are encouraged to breast feed, because it lowers estrogen."
Dr. Gary Proulx, medical director of radiation oncology at Exeter Center for Cancer Care is also a Massachusetts General physician. One of the things he feels makes Exeter Hospital stand out is the use of Intra Operative Radiation Therapy (IORT).
IORT means that, during surgery, certain patients can receive a one-time radiation treatment that may replace the standard five weeks of treatment.
Proulx said Exeter is the only New Hampshire hospital he is aware of that is using IORT. The main criteria to be eligible is that the patient be in an early stage of the disease.
"It's one time and done," said Proulx. "That's instead of five days a week, often twice a day. If it is appropriate for the patient, why wouldn't you use this tool? It's safer, giving no significant radiation exposure to the patient or the nearby staff treating them. "
There is an added bonus to the IORT treatment. Proulx said it represents a significant cost savings over the routine treatment course.
"The quality of life is better," Proulx said. "Many breast cancer patients are working women, are mothers raising families. This removes the disruption of five weeks of daily treatment."
There is a new possible use of the IORT treatment that Proulx said makes him very optimistic.
"We are looking at including all patients who choose to keep their breasts," said Proulx. "That is coming down the road and I think it is very exciting."
Because of Cheryl Bougie, RN, nurse navigator at the Exeter Hospital Center for Cancer Care, a patient is never on her own, from diagnosis through recovery. There is always someone to turn to who will answer questions, or just be there to talk.
"I am with the patient from the time of their screening (mammogram) and subsequent diagnosis," said Bougie. "My role is to prevent barriers to their care. There are many obstacles to overcome during treatment, unique to each patient."
A patient might have financial issues that they are concerned about, or they might lack transportation to get to treatments. Bougie will work with that. If the patient is having a hard time emotionally, she will work with that. Patients depend on her.
"I will be an advocate to get them on the appropriate path," said Bougie. "I am their liaison to, and a part of, the multidisciplinary team they will be working with."
A big part of Bougie's role is to help minimize the patient's fear. It is terrifying to get a diagnosis of cancer, even though most breast cancers are curable today.
"I can talk with them about what to expect once they have received a diagnosis," she said. "They can call me with questions. I will call them back and ask – do you need to talk? What can I do to make this easier for you?"


Palm oil is like green gold now", said Sukanto Tanoto, Indonesia's richest individual and owner of palm-oil, forestry and energy corporation RGM International.  Indeed, the global palm-oil market is booming and this is largely because of the growing production of biodiesel. Palm oil is not only one of the main feedstocks for biodiesel, it's also the primary substitute for rapeseed oil, which is in short supply in Europe because of its conversion into biodiesel.
In Malaysia and Singapore, home base to some of the world's largest palm-oil producers, biodiesel activity is at frenzied levels. Companies are merging, buying others out and forming all kinds of alliances to take advantage of the new market opportunities. Late in 2006, the three leading Malaysian palm-oil companies controlled by the state investment holding company Permodalan Nasional Bhd (Golden Hope Plantations, Sime Darby, and Kumpulan Guthrie) merged to form Synergy Drive, the world's largest listed oil-palm company. The combined company now controls 526,000 hectares of oil-palm plantations in Malaysia and Indonesia and is involved in several planned biodiesel factories.
For the major producers, a key focus is on expanding and integrating refining capacity both at home and abroad. In early 2007, the Federal Land Development Authority (FELDA), the largest palm-oil manufacturer in the world, purchased US-based Twin Rivers Technologies, which operates the US's largest biodiesel processing facility. Malaysia's IOI Corporation recently took over Unilever's European palm-oil processing operations, bought up two Malaysian palm-oil refinery companies and then publicly acknowledged its intentions to take over Asiatic Development, another major palm-oil producer and refiner. IOI is currently constructing a 200,000-tonne-per-year biodiesel refinery in Johor, Malaysia and Europe's largest palm-oil refinery in Rotterdam, the Netherlands, with a capacity to refine 900,000 tonnes a year into cooking oil or biodiesel. The Kuok Group is in similar expansion mode.
China National Offshore Oil Co. and Hong Kong Energy Ltd.
Builiding a 250,000 tonne per year biodiesel plant in Kuala Tanjung, North Sumatra called, Nusantara Bio Fuel.
Launched a joint venture for the construction and operation of two biodiesel plants in Malaysia and Singapore.
In 2006, BioX signed a 10-year supply agreement with IOI and Golden Hope Plantations. Deal with IOI includes the construction of a biofuel powerplant at IOI's refinery in Rotterdam. BioX Group also has joint ventures with Tradewinds Plantations and Sime Darby for carbon trading projects at their oil palm refineries.
Cargill, for its part, has been steadily expanding and integrating its palm-oil operations to take advantage of the surge in demand for the commodity. The company operates two refineries in Malaysia and a crushing plant in Indonesia. It has also recently boosted the capacity of its Rotterdam plant to refine tropical oils – an additional 200,000 tonnes per year of coconut oil and 300,000 tonnes per year of palm oil. On the production side, Cargill launched its first palm-oil plantations in Sumatra, Indonesia in 1997. Then, in 2005, Cargill and Temasek Holding, a private investment arm of the Singapore government, acquired the CDC Group's palm plantations in Indonesia and Papua New Guinea. These include a plantation in Kalimantan, Indonesia and a majority shareholding in four other plantations in the region – three in Indonesia and one in Papua New Guinea. Cargill's existing plantations were merged into the new joint venture, registered in Singapore as CTP Holdings, with Cargill, as its majority shareholder, assuming complete managerial and operational responsibilities.
Overall, then, the demand for biodiesel is encouraging consolidation in the palm-oil sector and a shift to a more transnational orientation and structure, with tighter integration between foreign companies and palm-oil producers and suppliers.
The Kuok Group of companies is an important but largely unknown agrofuels player, both in biodiesel and ethanol. Wilmar International holds around 435,000 hectares of oil-palm plantations and 25 refineries in Indonesia, Malaysia and Singapore. Through its alliance with ADM, it has a 300,000-tonne-per-year biodiesel refinery in Singapore, and the two companies have another three refineries set to come into production in Riau, Indonesia, each with a capacity of 350,000 tonnes per year, as well as a refinery in Rotterdam with a capacity of 1 million tonnes per year, making Wilmar easily one of the largest biodiesel producers in the world. The company, through its Malaysian subsidiary Josovina, is also to be the exclusive palm-oil supplier to Global Bio-Diesel, a 500,000-tonne-per-year biodiesel operation being built in Malaysia by the South Korean company Eco Solutions. And when it comes to the important trade link in the biodiesel chain, Kuok owns Singapore-based Pacific Carriers – one of the largest shipping companies in South-east Asia.
The Kuok Group's ethanol activities spring from its large sugar operations. Since he first ventured into the sugar business in the 1950s, Robert Kuok has steadily expanded the global reach of his operations. In the 1970s, together with the Salim Group, an Indonesian palm-oil and food company owned by Kuok's close associate Liem Sioe Liong, he established the country's largest sugar plantation and became the main supplier to the Suharto government's purchasing agency. Then, in 1987, Kuok, through his Singapore-based company Kerry International, purchased a 30 per cent share of the French sugar giant, Sucres et Denrées (Sucden), which controls around 15 per cent of the global sugar trade. More recently, Kuok, through his individual holdings and through Sucden, became the second largest shareholder in Cosan, Brazil's largest sugar processor and ethanol producer.
2 Wan Zhihong, "COFCO to invest US$1b in ethanol", China Daily, 19 October 2006.
1 APRIL-Watch, 11 May 2007.
2 Shibu itty Kuttickal, "Palm oil merger may deter some projects", ICIS News, 1 December 2006.


Male pythons are tagged with radio transmitters, allowing researchers to track the male as it moves toward breeding females.
The 17-foot, 140-pound female snake — an invasive species devastating to native wildlife — was discovered using a new tracking approach that leans on technology and the laws of attraction.
Burmese pythons caught in Florida are often 6 to 10 feet long, according to the Florida Fish and Wildlife Conservation Commission. In their native lands, the snakes commonly reach 18 feet and can exceed 20 feet.
Male pythons are tagged with radio transmitters, allowing researchers to track the male as it moves toward breeding females. The female python that wildlife officials found last week contained 73 developing eggs. The breeding season for Burmese pythons is between January and April.
"The team not only removes the invasive snakes, but collects data for research, develop new removal tools, and learn how the pythons are using the Preserve," FWC officials wrote in a statement on Facebook announcing the catch.
Florida has used other methods to manage the python population, including encouraging the humane killing of pythons on private property and at 22 wildlife management areas, including Big Cypress. The state has also sponsored removal programs with prize incentives, such as the Python Pickup Program and regular public hunts.
The state also encourages the public to share the locations of python sightings to help better track the snakes' whereabouts.
A 2012 study showed that since 1997, population growth for raccoons in the Everglades had dropped 99.3%, opossums 98.9% and bobcats 87.5%.
"Marsh rabbits, cottontail rabbits, and foxes effectively disappeared," according to the U.S. Geological Survey.


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Scoops was a weekly British science fiction magazine in tabloid format that was published by Arthur Pearson (pictured) for 20 issues in 1934. Its editor was Haydn Dimmock, who also edited The Scout, a weekly magazine for boys. Scoops was launched as a boy's paper, and it was not until several issues had appeared that Dimmock discovered there was an adult audience for science fiction.
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KQEG-CD, channel 23, is a Digital Class A television station licensed in La Crescent, Minnesota, with studios and offices in La Crosse, Wisconsin. WEZY-LP, channel 51, is a translator station located in Tomah, Wisconsin; WBOO-LP, channel 45, is a translator station located in Elk Mound, Wisconsin.The three stations are owned by Magnum Radio, Inc.
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A CD-R (also called Compact Disc Recordable) is a compact disc that can be recorded once. When people record a compact disc, they put either music or data on it.. A compact disc that can be recorded multiple times (and erased) is the CD-RW.. When you put data onto a CD, it is called burning a disc. A laser "burns" pits into a dye layer on the disc, making them transparent.
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Willie Hugh Nelson (born April 29, 1933) is an American singer, songwriter, musician, actor, producer, author, poet, and activist. The critical success of the album Shotgun Willie (1973), combined with the critical and commercial success of Red Headed Stranger (1975) and Stardust (1978), made Nelson one of the most recognized artists in country music. He was one of the main figures of outlaw ...
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CD-R - Simple English Wikipedia, the free encyclopedia. A CD-R (also called Compact Disc Recordable) is a compact disc that can be recorded once. When people record a compact disc, they put either music or data on it.. A compact disc that can be recorded multiple times (and erased) is the CD-RW.. When you put data onto a CD, it is called ...
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CD synonyms, CD pronunciation, CD translation, English dictionary definition of CD. The symbol for cadmium. abbr. 1. certificate of deposit 2. civil defense 3. cluster of differentiation antigen 4. compact disc 5. French corps diplomatique... CD - definition of CD by The Free Dictionary. ... Encyclopedia; Wikipedia
CD-R | Article about CD-R by The Free Dictionary
To tell if a CD-R was burned, look for the slight change in reflectivity on the recording side. In this example, only 6% of the disc has been written, and the arrows point to the end of the recorded area (look carefully). Burning a CD-R; To "burn" a CD-R, the files are dragged and dropped into a recording window as in this Easy CD Creator example.
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Other categories; 2001 Categories & Criteria (version 3.1) Description 1994 Categories & Criteria (version 2.3) Extinct in the Wild (EW), known only to survive in cultivation, in captivity or as a naturalized population (or populations) well outside the past range. Data Deficient (DD), inadequate information to make a direct, or indirect, assessment of its risk of extinction.
Wikipédia, l'encyclopédie libre
Amour endormi est un tableau de Caravage peint en 1608 à Malte.Il représente le personnage mythologique de Cupidon alias Amour, plongé dans un profond sommeil et dont le corps vivement éclairé se détache sur un fond très sombre. Contrairement à un autre tableau de Caravage intitulé L'Amour vainqueur (Amor Vincit Omnia) et réalisé environ six ans plus tôt autour d'un thème ...
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Looking for online definition of DVD-ROM or what DVD-ROM stands for? DVD-ROM is listed in the World's largest and most authoritative dictionary database of abbreviations and acronyms The Free …
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Wikipedia è un'enciclopedia online, collaborativa e libera. Grazie al contributo di volontari da tutto il mondo, Wikipedia è disponibile in oltre 290 lingue . Chiunque può contribuire alle voci esistenti o crearne di nuove, affrontando sia gli argomenti tipici delle enciclopedie tradizionali sia quelli presenti in almanacchi, dizionari ...
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A subscription Web site debuted in 1998, and an abridged version of Encarta was made available online for free in 2000, with full access available to purchasers of the CD or DVD products. Microsoft began charging for access to all encyclopaedia content the following year, though access to dictionary content remained free.
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CD-RW - Simple English Wikipedia, the free encyclopedia
A CD-RW (which stands for Compact Disc ReWritable) is a Compact disc that can be recorded and erased multiple times. It can hold data or music. Most of the time it will hold data, since many CD players can not play CD-RWs. During its development, the format was known as CD-E, which stands for Compact Disc Erasable.
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That it can satisfy cravings for cocaine in a way that is subjectively and pharmacologically equivalent but longer-lasting as well as easier on the body and somewhat safer and easier to manage has long been part of the 'street lore' associated with stimulants in many parts of the world. ^ Many patients' ADD symptoms return immediately after stopping stimulants, so they restart their medication ...
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A CD-R (Compact Disc-Recordable) is a variation of the Compact Disc invented by Philips and Sony.CD-R is a Write Once Read Many (WORM) optical medium, though the whole disk does not have to be entirely written in the same session.. CD-R retains a high level of compatibility with standard CD readers, unlike CD-RW - which can be re-written, but is not capable of playing on many readers, and …
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CD-ROM: CD-ROM, type of computer memory in the form of a compact disc that is read by optical means. A CD-ROM drive uses a low-power laser beam to read digitized (binary) data that has been encoded in the form of tiny pits on an optical disk. The drive then …
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Early life and influences. A. R. Rahman was born in a musically affluent Tamil family. His father R. K. Shekhar, was a Chennai based composer and conductor for Malayalam films.Rahman lost his father at a young age and his family rented out musical equipment as a source of income.
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BASF constantly strives to develop innovative products and concepts for various applications in the personal and beauty care markets, and aims to help its customers leverage the most current trends. At this year's In-Cosmetics, the world's leading supplier of high-quality ingredients and actives for the personal care industry will give customers the opportunity to experience the pulse of consumers at their booth. BASF's Care Chemicals experts will also present their new communication strategy and will share insights into their innovative approaches towards the personal care market.
People's daily lives are characterized by the need to make themselves stand out, while taking part in society. As such, individualization and authenticity can be considered as mega and macro trends. Consumers' individuality as well as collectivity impact their lifestyle, priorities and the things they like – and greatly influence which products they buy. According to their personalities, consumers can be divided into different groups, and manufacturers are looking for ways to meet the specific demands of each consumer type. BASF's new concept focuses on these different consumer lifestyles and includes solutions that meet the various needs.
From matte-like to high sparkle – pigments and specialty minerals are often used in cosmetics, beauty care and personal care products to provide certain effects. With its broad portfolio of specialty minerals and effect pigments, BASF offers customers the option to choose from a range of colors and from natural looking, vibrant, shiny and metallic shades. The portfolio also includes the company's new synthetic mica-based pigments that provide a lustrous shine, swirls of shimmer as well as high chromaticity and high purity. Whether for him or her, the new pigments are suitable in various formulations and can even help to create a flawless, natural appearance of the skin.
People's hair can make a big difference as to how they feel on any particular day as well as on their overall sense of well-being. At In-Cosmetics, BASF will launch a range of new ingredients for hair-care products that can help people to have the style they want. The products will be on display at the company's booth and will also be presented at an innovation seminar on April 19, 2012.
Caring for and styling curly hair, which is typical for Africans, Latin and African Americans, can be especially challenging. Relaxers are already commonly used, but often cause hair damage. As a result, consumers are increasingly looking for new products that allow the hair to be straighter and at the same time to be conditioned, protected and strengthened. To improve both the mechanical stability and tactile properties of the relaxed hair without influencing the straightening efficacy, BASF has developed a novel compound that can be easily incorporated into lye relaxer formulations.
Formulating hair styling gels that offer high setting performance is another major challenge for the hair-care industry. Traditional thickeners can only be combined with a limited choice of styling polymers, and so BASF has developed a new liquid thickener that's tailor-made for clear and smooth hair styling gels. It is cold processable, easy to handle and shows a high setting performance due to synergy effects with conventional styling polymers.
BASF Beauty Care Solutions and Laboratoires Sérobiologiques - now with Beauty Care Solutions - will be showcasing their latest cosmetic actives addressing both major skin care issues – skin aging and skin pigmentation, with proven efficacy and visible results. Both ingredients are of botanical origin and comply with major international cosmetic regulations meeting the requirements of cosmetic manufacturers.
"We want to shape the personal care market, both today and in the future and therefore, at BASF, we strive for a deep understanding of consumer needs and habits. This understanding along with our technological excellence and formulation expertise makes us a valued partner for the personal care industry." says Thomas Schroeder, BASF Business Manager Personal Care Europe. "We will also continue to focus on consumer trends such as well-being and sustainability in order to work closely with our customers towards sustainable market success." During the course of the exhibition, BASF experts will take part in various official sessions, including workshops, innovation seminars and podium discussions, where they will share their knowledge and provide insights into the market.
Scientific Seminar: "Spotlight on Sun Protection"
BASF's Care Chemicals division offers a broad portfolio of products for hygiene, personal care, home care, industrial & institutional cleaning as well as technical applications. Through the acquisition of Cognis, Care Chemicals has become the leading supplier to the cosmetics industry and has strengthened its number one position in products for the detergents and cleaners industry. The high quality product portfolio of the division mainly comprises surfactants, polymers, emollients, chelating agents, UV filters and biocides. The offering is completed by superabsorbents, developed for the requirements in all fields of hygiene applications. Care Chemicals operates production and development sites as well as sales offices all over the world.


With the constant evolution of the gun making industry, Atkin Grant & Lang are striving to preserve the history and heritage of Best English shotguns.
Where other Gunmakers are focusing solely on producing modern guns, Atkin Grant & Lang Gun & Rifle Makers are keeping their rich history at the forefront of future development plans. As well as designing and making their new shotguns and rifles, they are also refurbishing old, second hand Henry Atkins, Stephen Grants and Joseph Langs.
This process gives a new lease of life to well-loved guns and combines mechanical perfection with years of history. The team of supremely skilled gunmakers merge the latest machining techniques with years of hands on experience to produce a truly bespoke gun, re-built specifically to satisfy the customer's requirements with years of unique history. A gun that could tell a thousand stories.


In memory of Harvey Ball. Inspiration For the first time in history, in 2015 the Oxford Dictionaries chose a pictogram, to be exact an emoji, as the word of the year. Emoji is a Japanese word, the 'e' means picture + 'moji' means a letter / character. The similar sounding English word emoticon (emotion icon) helped the Japanese word to spread. History The incredible rise of emojis is a fascinating cultural and linguistic phenomenon. Its history goes back to the roots of modern writing that developed from pictures: pictograms and ideograms. The earliest examples of writing come from the pictographic Egyptian hieroglyphs and Mesopotamian cuneiform scripts around 5,000 years ago. During the early first millennium BC the Phoenician alphabet became the ancestor of multiple writing systems across the Middle East, Europe, northern Africa and South Asia. Emoticons are pictograms that were created using alphabetical punctuation by like semicolons, colons and brackets. The "smiley" was born in 1963 when Harvey R. Ball, owner of an advertising agency in the USA, came up with the idea to use it to lift the mood of the workers of a recently merged insurance company. The company has paid him 45 dollars for this invention that he never claimed the rights for. However, Nicolas Loufrani has some doubts about the origin - supposedly there is a 4500 years old rock that have been found in a French cave that has a "smiley" on it. 1982 Scott E. Fahlman, a professor at the Carnegie Mellon University, typed the first :-) Starting from the widespread use on Japanese mobile phones in the late 1990's, emojis multiplied in form and variety and conquered the world's electric discourse. By the end of 2015 they were so widespread that - for the first time ever - a pictogram i.e. a picture was chosen as the 'Word of the Year 2015". They infuse contemporary digital conversations with facial expressions and gestures, adding a human touch the midst of text-based cyber communication. This is a buffling reverse transformation: first, pictography writing became simplified and alphabetical, then pictograms were reinvented by using alphabetical writing. Ball.Room. Installation The installation is a 25 m2 large, transparent room filled with exactly 2015 yellow beach balls. The artist created 65 different well-known as wellas new emojis using 14 character sets of different typefaces (Avant Garde Gothic, Avenir, Frutiger, Helvetica, Eurostile, Futura, Courier, Didot, Trajan, Caslon, Baskerville, Garamond, Times, Pistilli). At the end oft he exhibition visitors can take home a ball. In exchange, they write down a word of their choice on a card and placeit in a box. At the end of the exhibition the artist createsa new ball with the word that comes up most frequently, "The Word of the Exhibition". With the Ball.Room. installation the artist and the visitors interactively transfer pictography back into alphabetic writing. Art history The exhibition has an art history background similar to Andy Warhol's Silver Clouds inflatable installation, the dutch Florentijn Hofman's giant duck Rubber Duck, Geraldo Zamproni's inflated red Pillow Talk, the FriendsWithYou inflated sculptures, Kurt Perschke's Redball Project or Jeff Koons's balloon imitating metal sculptures.
I have created 65 different well-known as well as new emojis that have been put on 2015 (that's when an emoji became the word of the year) yellow inflatable beach balls using 14 character sets of different typefaces (Avant Garde Gothic, Avenir, Frutiger, Helvetica, Eurostile, Futura, Courier, Didot, Trajan, Caslon, Baskerville, Garamond, Times, Pistilli). Then I filled up a room with these yellow balls. Every visitor can take a beach ball home in exchange of a single word they come up with that they place into a box. At the end of the exhibition the word that most people have written down will become the word of this exhibition and will be written down on an empty ball. The more places this exhibition will be held the more interesting it will be to see the chosen words from that certain exhibition, will it be affected by a nation or a geographical location?
"Every visitor can take a beach ball home in exchange of a single word they come up with that they place into a box." 12 hours after the Opening every "emojiballs" were adobted by the visitors.