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Korean J Intern Med > Volume 34(1); 2019 > Article
Nam, Jang, Hwang, Kim, Park, and Park: Nonpulmonary risk factors of acute respiratory distress syndrome in patients with septic bacteraemia
Korean J Intern Med 2019;34(1):116-124.
Published online: June 14, 2018
DOI: https://doi.org/10.3904/kjim.2017.204
Nonpulmonary risk factors of acute respiratory distress syndrome in patients with septic bacteraemia
Hyunseung Nam1, Seung Hun Jang2, Yong Il Hwang2, Joo-Hee Kim2, Ji Young Park2, Sunghoon Park2
1Department of Internal Medicine, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
2Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
Correspondence to Sunghoon Park, M.D. Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 14068, Korea Tel: +82-31-380-3715 Fax: +82-31-380-3973 E-mail: f2000tj@gmail.com
Received June 7, 2017 Revised January 7, 2018 Accepted March 5, 2018
Copyright © 2019 The Korean Association of Internal Medicine
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background/Aims
The relationship between nonpulmonary organ failure and the development of acute respiratory distress syndrome (ARDS) in patients with sepsis has not been well studied.
We retrospectively reviewed the medical records of patients with septic bacteremia admitted to the medical intensive care unit (ICU) of a tertiary academic hospital between January 2013 and December 2016.
The study enrolled 125 patients of median age 73.0 years. Urinary (n = 47), hepatobiliary (n = 30), and pulmonary infections (n = 28) were the most common causes of sepsis; the incidence of ARDS was 17.6%. The total number of nonpulmonary organ failures at the time of ICU admission was higher in patients with ARDS than in those without (p = 0.011), and the cardiovascular, central nervous system (CNS), and coagulation scores were significantly higher in ARDS patients. On multivariate analysis, apart from pneumonia sepsis, the CNS (odds ratio [OR], 1.917; 95% confidence interval [CI], 1.097 to 3.348) and coagulation scores (OR, 2.669; 95% CI, 1.438 to 4.954) were significantly associated with ARDS development. The 28-day and in-hospital mortality rates were higher in those with ARDS than in those without (63.6 vs. 8.7%, p < 0.001; 72.7% vs. 11.7%, p < 0.001), and ARDS development was found to be an independent risk factor for 28-day mortality.
Apart from pneumonia, CNS dysfunction and coagulopathy were significantly associated with ARDS development, which was an independent risk factor for 28-day mortality.
Keywords: Respiratory distress syndrome, adult; Bacteremia; Organ failure; Sepsis
Sepsis remains a major public health problem, accounting for 5.2% of the total United States hospital costs in 2011, and is the primary cause of death from infection [1]. The development of acute respiratory distress syndrome (ARDS) is not uncommon among patients with sepsis, triggered by a direct lung injury caused by pneumonia or an indirect lung injury attributable to infection of a distant organ (e.g., acute pancreatitis).
Less is known about the relationship between nonpulmonary organ failure and ARDS development. One multicenter observational study found that pneumonia sepsis was associated with ARDS development [2]. In another observational prospective study, 4.6% of patients with extrapulmonary conditions developed ARDS. The likelihood of developing ARDS (or acute lung injury) was 35.6% in patients with shock and 1.4% in those with nonpulmonary sepsis without shock [3]. However, because the lungs are one of the targets of an overwhelming acute systemic inflammatory response, the recognition of nonpulmonary organ failure as a risk factor for developing ARDS seems to be important [4].
Multiorgan dysfunction in patients with sepsis is associated with increased in-hospital mortality. However, the data on the association between ARDS development and in-hospital mortality in patients with sepsis are conflicting. Two studies reported that, after adjusting for confounding factors, ARDS development after sepsis onset was not associated with an increased risk of mortality [5,6], while an epidemiological study found the opposite [7]. Therefore, we explored whether ARDS is a risk factor for hospital death in patients with sepsis.
In this study, we evaluated nonpulmonary organ failure associated with the risk of ARDS development and the impact of ARDS on mortality in patients with septic bacteremia.
This retrospective study was performed in a tertiary academic hospital (830 beds) from January 1, 2013 to December 31, 2016. Adult patients (aged ≥ 18 years) with septic bacteremia admitted to the medical intensive care unit (ICU) were screened initially. Bacteremia was diagnosed when at least two blood cultures were positive. The exclusion criteria were (1) a positive blood test result believed to be caused by contamination (i.e., only one positive culture); (2) liver cirrhosis (≥ Child-Pugh B grade); (3) an uncontrolled hematological malignancy or a solid cancer; (4) use of steroids or immunosuppressants; (5) cardiopulmonary resuscitation upon ICU admission; and (6) a do-not-resuscitate status. However, cancer patients were eligible if they had been in complete remission for > 6 months, and patients who were taking low-dose steroids (i.e., ≤ 10 mg/day prednisolone or the equivalent) were also eligible. We used the Sepsis-3 definition to diagnose sepsis [8,9] and followed the treatment recommendations of the Surviving Sepsis Campaign [10,11]. We used the Berlin definition of ARDS [12]. We measured ARDS incidence during the first week of sepsis and classified ARDS severity according to the ratio of the arterial oxygen tension to the inspired oxygen fraction (PaO2/FiO2): mild (200 < PaO2/FiO2 ≤ 300 mmHg), moderate (100 < PaO2/FiO2 ≤ 200 mmHg), and severe ARDS (PaO2/FiO2 ≤ 100 mmHg).
The study was approved by the Hallym University Institutional Review Board (approval no. 2017-I049). The need for informed consent was waived because of the retrospective nature of the work.
Data collection and outcomes
We retrieved demographic characteristics and the following data by retrospective review of medical records: body mass index, the cause of sepsis, the organisms identified (and whether they were Gram-positive or -negative), sequential organ failure assessment (SOFA) scores and scores on the individual components thereof, and simplified acute physiology score II (SAPS II) at ICU admission. Laboratory data (i.e., the levels of lactate, C-reactive protein, and brain natriuretic peptide [BNP]), the appropriateness of empirical antibiotics, and bacterial multidrug resistance were also investigated. We used the six individual components of the SOFA to assess organ failure, which was performed before ARDS developed; organ failure was considered present when any individual score was ≥ 2.
The primary outcomes were the associations between nonpulmonary organ failure and ARDS development; we also sought independent factors predicting ARDS development. The secondary outcome was the effect of ARDS on 28-day mortality.
All categorical variables are presented as numbers with percentages, and all continuous variables as medians with interquartile ranges (IQRs), while survival times are presented as means and standard deviation. The Mann-Whitney U test was used to compare continuous variables, and the chi-square or Fisher's exact test to compare categorical variables. Logistic regression analysis was performed using covariates that were significant (p < 0.05) on univariate analysis to identify independent risk factors for ARDS development; we employed a backward stepwise selection method based on the likelihood ratio. Kaplan-Meier survival curves with log-rank tests and Cox proportional hazard models based on a multivariate approach were also used. IBM SPSS for Windows version 22.01 (IBM Co., Armonk, NY, USA) was used for all statistical analyses.
During the study period, 144 patients with septic bacteremia were screened initially; of these, 125 were enrolled (Fig. 1). The median patient age was 73.0 years (IQR, 59.0 to 80.0), and 67 were male (Table 1). Sepsis and septic shock accounted for 51.2% and 48.8% of all patients, respectively; urinary tract infection (n = 47) was the most common cause of sepsis, followed by hepatobiliary infection (n = 30). Methicillin-resistant Staphylococcus aureus was the most common Gram-positive pathogen (17/31) and Escherichia coli the most common Gram-negative bacterium (52/94) (Table 2). Forty-three patients (34.4%) were infected by multidrug-resistant pathogens, and 11 received inappropriate empirical antibiotics (Table 3). The overall incidence of ARDS was 17.6% (22/125); those with pneumonia and skin and soft tissue infections had ARDS incidences of 35.7% (10/28) and 37.5% (3/8), respectively (Fig. 2). The median interval between ICU admission and ARDS development was 1.0 days (range, 0.5 to 3.0), and the number of patients with mild, moderate, and severe ARDS was four (18.2%), five (22.7%), and 13 (59.1%), respectively. Regarding hospital outcomes, both 28-day and in-hospital mortality rates were higher in patients with ARDS than in those without ARDS (63.6% vs. 8.7%, p < 0.001; 72.7% vs. 11.7%, p < 0.001) (Table 3).
Organ failure and ARDS development
Patients who developed ARDS had higher SAPS II and SOFA scores at the time of ICU admission compared with those who did not develop ARDS (Table 1). Of the six components of the SOFA score, the cardiovascular, central nervous system (CNS), respiratory, and coagulation scores were significantly higher in ARDS patients (Fig. 3A), and the incidence of ARDS increased with the number of nonpulmonary organ failures (Fig. 4). In addition, the cardiovascular, CNS, respiratory, renal, and coagulation scores were significantly higher in non-survivors than in survivors (Fig. 3B).
Risk factors for ARDS development
Univariate analyses indicated that a total of 12 variables (eight baseline variables and four organ failure scores) differed significantly between patients who did and those who did not develop ARDS (Table 1 and Fig. 3A). After considering overlaps in significance, we selected eight variables (pneumonia sepsis, Gram-negative infection, blood urea nitrogen level, C-reactive protein level, three organ failure scores [cardiovascular, CNS, and coagulation scores], and the number of nonpulmonary organ failures), as well as age and gender, to enter into the multivariate model. Seven variables remained in the final model (Table 4); among them, pneumonia sepsis (odds ratio [OR], 4.590), the coagulation score (OR, 2.669), the CNS score (OR, 1.917), and the C-reactive protein level (OR, 1.007) were independently associated with ARDS development.
ARDS development and 28-day mortality
In the univariate analyses, 16 variables (11 baseline variables and five organ failure scores) differed significantly between survivors and nonsurvivors (Table 5 and Fig. 3B). After considering overlaps in significance, we initially selected 11 variables (heart disease, Gram-negative infection, BNP, blood urea nitrogen, lactate, ARDS development, and five organ failure scores [the cardiovascular, CNS, respiratory, renal, and coagulation scores]), as well as age and gender, to enter into the multivariate model (Cox proportional hazard model). In the final model, in which seven variables remained, ARDS development (hazard ratio [HR], 7.448; 95% confidence interval [CI], 2.894 to 19.168), lactate (HR, 1.219; 95% CI, 1.087 to 1.367), and the renal score (HR, 2.034; 95% CI, 1.372 to 3.015) were independently associated with the 28-day mortality. In the Kaplan-Meier survival curves for 28-day survival, the mean survival time was significantly shorter in patients with ARDS than in those without ARDS (Fig. 5).
We report several interesting findings. First, among nonpulmonary organ dysfunctions, CNS dysfunction and coagulopathy were significantly associated with ARDS development in patients with septic bacteremia. Second, ARDS development was significantly associated with an increase in 28-day mortality.
We used the new Sepsis-3 definition, which aims to render diagnoses consistent and to facilitate early sepsis recognition [9]. The previous definitions of sepsis (Sepsis-1 and Sepsis-2 of 1991 and 2001, respectively) have been found to be invalid [13,14]. In addition, the task force that developed Sepsis-3 emphasized life-threatening organ dysfunctions [8,9,15]. In this context, we evaluated the role played by nonpulmonary organ failure in ARDS development early in sepsis.
Sepsis is a common cause of ARDS. Although ARDS incidence varies by infection site, the risk factors for ARDS development remain unclear. Seethala et al. [2] found that the Acute Physiology and Chronic Health Evaluation (APACHE) II score, pneumonia, pancreatitis, an acute abdomen, and shock were independently predictive of ARDS in septic patients. Moss et al. [16] found that pneumonia was an independent predictor of ARDS, consistent with what was found by Gattinoni et al. [17], who reported differences in respiratory mechanics and responses to positive end-expiratory pressure depending on whether ARDS was caused by a pulmonary or nonpulmonary source. In this study, we did not calculate lung injury scores, but patients with pneumonia (thus with higher respiratory SOFA scores) exhibited a significantly higher incidence of ARDS and a trend toward higher mortality, compared with the nonpneumonia group. Therefore, pulmonary infection may be significant in terms of ARDS development and may be associated with poor in-hospital outcomes.
Activation of coagulation and an unbalanced inflammatory reaction are characteristic of both ARDS and sepsis, triggering fibrin deposition in capillary beds, in turn causing organ dysfunction [18]. Recently, both neutrophil extracellular trapping and platelet aggregation have been recognized as key players during ARDS development in septic patients [19,20]. We found that the coagulopathic score was associated with ARDS development and a higher score seemed to be associated with mortality (p = 0.032) (Fig. 3B).
We believe that our work re-emphasizes the important role played by activation of coagulation during ARDS development and for 28-day mortality. In addition, CNS dysfunction was associated with ARDS development. It may develop secondarily to hypoxia, hypoglycemia, and/or hypotension in patients with sepsis and may reflect sepsis-induced multiorgan dysfunction. Although relevant data are sparse, Moss et al. [16] found that patients who chronically abuse alcohol had higher CNS scores and were at a higher risk of ARDS. In this context, we suggest that the impact of sepsis-associated CNS dysfunction on patient outcomes be investigated further.
The incidence of ARDS in the present study (17.6%) was lower than that in previous studies [16,21], perhaps because of differences in the severity of illness. Fifty-one percent of our patients had sepsis (vs. septic shock, 49.0%), and 37.6% had sepsis of urinary tract origin, which is regarded as less severe than other forms of sepsis. Of the patients evaluated by Seethala et al. [2], only 9.2% were in shock; the mean APACHE II score was 11.7, and the ARDS incidence was also low (6.2%). However, Eggimann et al. [6] evaluated patients similar to ours and reported an ARDS incidence of 15.8%, close to our figure. In the present study, ARDS development was significantly associated with an increased 28-day mortality, which contrasts previous observational studies [6,22,23]. After adjusting for the severity of illness and nonpulmonary organ dysfunction, Eggimann et al. [6] showed that, ARDS development was not independently associated with short-term mortality. This disparity may be the result of the different mortality rates of both ARDS and non-ARDS patients between the two studies. In particular, the 28-day and in-hospital mortality rates (63.6% and 72.7%, respectively) in our ARDS group seemed to be higher than those in previous studies. This could be attributable to their high severity of illness at the time of ICU admission (i.e., SAPS II score, 58; estimated death rate, 63%), and the fact that ARDS occurred in patients with pre-existing septic bacteremia.
Our study had several limitations. First, our patient numbers were small, and the retrospective nature of the work may have introduced unidentified bias. Second, our study population was heterogeneous in terms of the origin of sepsis. In particular, the frequency of sepsis derived from urinary tract infections (usually associated with a good prognosis) was higher than that of previous studies. However, we enrolled only patients with septic bacteremia to ensure a homogeneous study population. We also investigated the appropriateness of empirical antibiotic therapy and pathogen multidrug resistance. To our knowledge, very few data are available on the role played by nonpulmonary organ dysfunction for ARDS development in patients with sepsis. Previous studies suggested that the site of infection does not independently affect mortality [22,23]. Hence, physicians need to pay more attention to organ dysfunction than to specific infection sites when identifying high-risk patients and initiating early interventions.
In conclusion, our data indicate that among nonpulmonary organ dysfunctions, CNS dysfunction and coagulopathy are independent risk factors for ARDS development in patients with septic bacteremia, and ARDS significantly increases 28-day mortality.
KEY MESSAGE
1. Among nonpulmonary organ dysfunctions, central nervous system dysfunction and coagulopathy were independent risk factors for the development of acute respiratory distress syndrome (ARDS) in patients with bacteremia sepsis.
2. The development of ARDS was significantly associated with an increase in 28-day mortality in patients with bacteremic sepsis.
No potential conflict of interest relevant to this article was reported.
The authors want to thank Young Soo Ju (Hallym University Sacred Heart Hospital) for his contribution to statistical analysis.
Flow chart of patient enrolment into this study. CNS, central nervous system; ARDS, acute respiratory distress syndrome.
Acute respiratory distress syndrome (ARDS) frequencies according to the origin of sepsis. UTI, urinary tract infection; CRI, catheter-related infection; IE, infectious endocarditis.
Individual organ failure scores (A) of patients with and those without acute respiratory distress syndrome (ARDS) and (B) of 28-day survivors and non-survivors. SOFA, sequential organ failure assessment; CNS, central nervous system.
Acute respiratory distress syndrome (ARDS) incidence according to the number of nonpulmonary organ failures. The incidence of ARDS increased in patients with septic bacteremia and with the number of nonpulmonary organ failures.
Kaplan-Meier survival curves of the 28-day survival of patients with and without acute respiratory distress syndrome (ARDS). The mean survival time was significantly shorter in patients with ARDS than in those without ARDS (13.9 ± 2.4 days vs. 26.1 ± 0.6 days, log-rank test p < 0.001).
Comparisons of baseline characteristics between ARDS and non-ARDS patients
All patients (n = 125)
ARDS (n = 22)
Non-ARDS (n = 103)
Age, yr 73 (59.0–80.0) 65.0 (58.0–78.3) 73 (60–81) 0.176
Sex, male/female 67/58 12/10 55/48 0.922
Comorbid illness
Diabetes 54 (43.2) 10 (45.5) 44 (42.7) 0.814
Hypertension 62 (49.6) 9 (40.9) 53 (51.5) 0.369
COPD 3 (2.4) 0 3 (2.9) 1.000
CKD 21 (16.8) 2 (9.1) 19 (28.4) 0.363
Heart diseases 18 (14.4) 4 (18.2) 14 (13.6) 0.587
Cancer 10 (8.0) 2 (9.1) 8 (7.8) 0.689
Pneumonia vs. nonpneumonia 28/97 10/12 18/85 0.006
Sepsis/septic shock 64/61 11/11 53/50 0.901
PaO2/FiO2 250.0 (180.0–303.5) 165.0 (87.5–277.5) 254 (210–320) 0.002
Lactate, mmol/L 3.6 (2.4–5.8) 4.3 (2.8–9.4) 3.2 (2.3–5.6) 0.123
BNP, pg/mL 297.4 (138.5–973.4) 772.1 (115.1–1,389.0) 287.2 (138.7–927.5) 0.169
Blood urea nitrogen 31.1 (20.4–55.0) 43.4 (36.7–64.0) 29.8 (19.2–53.7) 0.033
C-reactive protein 172.9 (127.4–231.5) 195.9 (174.3–298.6) 167.2 (113.0–218.0) 0.011
SOFA 7.0 (5.5–9.0) 10.5 (7.0–15.3) 7.0 (5.0–9.0) < 0.001
SAPS II 44.0 (35.0–56.0) 58.0 (39.8–73.8) 41.0 (35.0–53.0) 0.001
Values are presented as median (interquartile range) or number (%).
ARDS, acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease; PaO2/FiO2, ratio of arterial oxygen tension to inspired oxygen fraction; BNP, brain natriuretic peptide; SOFA, sequential organ failure assessment; SAPS, simplified acute physiology score.
Isolated organisms among enrolled patients
Organisms identified
No. (%)
Gram-positive organisms
Streptococcus pneumoniae 7 (5.6)
Streptococcus viridans 1 (0.8)
Methicillin-sensitive Staphylococcus aureus 17 (13.6)
Methicillin-resistant Staphylococcus aureus 3 (2.4)
Other organismsa 3 (2.4)
Gram-negative organisms
Escherichia coli 52 (41.6)
Klebsiella pneumoniae 26 (20.8)
Pseudomonas aeruginosa 3 (2.4)
Proteus mirabilis 3 (2.4)
Citrobacter freundi 3 (2.4)
Acinetobacter baumannii 3 (2.4)
Other organismsb 4 (3.2)
a Enterococcus faecalis (n = 1), Staphylococcus hominis (n = 1), and Staphylococcus epidermidis (n = 1).
b Enterobacter aerogenes (n = 1), Serratia marcescens (n = 1), Enterobacter cloacae (n = 1), and Edwardsiella tarda (n = 1).
Treatments and outcomes between ARDS and non-ARDS patients
Non- ARDS (n = 103)
MDR pathogens 43 (34.3) 5 (22.7) 38 (36.9) 0.204
Gram(+)/(–) pathogens 31/94 10/12 21/82 0.013
Inappropriate antibiotics 11 (8.9) 2 (9.1) 9 (8.8) 1.000
Mechanical ventilation 35 (28.5) 15 (68.2) 20 (19.4) < 0.001
Vaosopressors 81 (64.8) 16 (72.7) 65 (63.1) 0.467
ICU mortality 24 (19.2) 14 (63.6) 10 (9.7) < 0.001
28-Day mortality 23 (18.4) 14 (63.6) 9 (8.7) < 0.001
Hospital mortality 28 (22.4) 16 (72.7) 12 (11.7) < 0.001
Values are presented as number (%).
ARDS, acute respiratory distress syndrome; MDR, multidrug resistance; ICU, intensive care unit.
Multivariate analysis for risk factors of ARDS development
Unadjusted OR
Adjusted OR
95% CI
Age 0.977 0.945–1.009 0.979 0.936–1.023
Male sex 0.955 0.379–2.406 1.022 0.310–3.371
Pneumonia sepsis 3.935 1.475–10.498 4.590 1.177–17.895
Gram-negative infection 0.307 0.117–0.808 0.377 0.107–1.326
Coagulation score 1.836 1,219–2,766 2.669 1.438–4.954
CNS score 2.117 1.355–3.309 1.917 1.097–3.348
C-reactive protein 1.006 1.001–1.011 1.007 1.001–1.013
Hosmo-Lemeshow test, chi-sqaure = 3.875 (df = 8), p = 0.398.
ARDS, acute respiratory distress syndrome; OR, odds ratio; CI, confidence interval; CNS, central nervous system.
Comparisons between 28-day survivors and nonsurvivors
Survivors (n = 102)
Nonsurvivors (n = 23)
Age, yr 73 (59.0–80.0) 73.0 (59.0–79.0) 75.0 (59.0–81.0) 0.954
Sex, male/female 67/58 53/49 14/9 0.439
Hypertension 62 (49.6) 52 (51.0) 10 (43.5) 0.516
COPD 3 (2.4) 3 (2.9) 0 1.000
CKD 21 (16.8) 14 (13.7) 7 (30.4) 0.066
Heart diseases 18 (14.4) 11 (10.8) 7 (30.4) 0.023
Pneumonia vs. nonpneumonia 28/97 19/83 9/14 0.033
Sepsis/septic shock 64/61 55/47 9/14 0.200
MDR pathogens 43 (34.4) 34 (33.3) 9 (39.1) 0.597
Gram (+) vs. (–) pathogens 31/94 20/82 11/12 0.005
Inappropriate antibiotics 11 (8.9) 8 (7.9) 3 (13.0) 0.426
ARDS 22 (17.6) 8 (7.8) 14 (60.9) < 0.001
Vasopressors 81 (64.8) 63 (61.8) 18 (78.3) 0.135
PaO2/FiO2 250.0 (180.0–303.5) 260 (210.0–320.0) 170.0 (100.0–254.0) 0.003
Lactate, mmol/L 3.6 (2.4–5.8) 3.1 (2.5–5.3) 5.6 (3.1–11.4) 0.011
BNP, pg/mL 297.4 (138.5–973.4) 273.9 (128.4–780.3) 1,040.4 (234.5–2,549.4) 0.005
SOFA 7.0 (5.5–10.0) 7.0 (5.0–9.0) 13.0 (9.0–14.0) < 0.001
SAPS II 44.0 (35.0–56.0) 41.0 (33.0–48.0) 61.0 (57.0–77.0) < 0.001
COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease; MDR, multi-drug resistance; ARDS, acute respiratory distress syndrome; PaO2/FiO2, ratio of arterial oxygen tension to inspired oxygen fraction; BNP, brain natriuretic peptide; SOFA, sequential organ failure assessment; SAPS, simplified acute physiology score.
1. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Statistical Brief #160. United States. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs Rockville (MD): Agency for Healthcare Research and Quality (US), 2006. [cited 2018 May 29]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK169005/.
2. Seethala RR, Hou PC, Aisiku IP, et al. Early risk factors and the role of fluid administration in developing acute respiratory distress syndrome in septic patients. Ann Intensive Care 2017;7:11.
3. Ferguson ND, Frutos-Vivar F, Esteban A, et al. Clinical risk conditions for acute lung injury in the intensive care unit and hospital ward: a prospective observational study. Crit Care 2007;11:R96.
4. Del Sorbo L, Slutsky AS. Acute respiratory distress syndrome and multiple organ failure. Curr Opin Crit Care 2011;17:1–6.
5. Russell JA, Singer J, Bernard GR, et al. Changing pattern of organ dysfunction in early human sepsis is related to mortality. Crit Care Med 2000;28:3405–3411.
6. Eggimann P, Harbarth S, Ricou B, et al. Acute respiratory distress syndrome after bacteremic sepsis does not increase mortality. Am J Respir Crit Care Med 2003;167:1210–1214.
7. Mikkelsen ME, Shah CV, Meyer NJ, et al. The epidemiology of acute respiratory distress syndrome in patients presenting to the emergency department with severe sepsis. Shock 2013;40:375–381.
8. Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock: for the third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:775–787.
9. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:801–810.
10. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580–637.
11. Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008;34:17–60.
12. ARDS Definition Task Force; Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012;307:2526–2533.
13. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;20:864–874.
14. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Intensive Care Med 2003;29:530–538.
15. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: for the third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:762–774.
16. Moss M, Parsons PE, Steinberg KP, et al. Chronic alcohol abuse is associated with an increased incidence of acute respiratory distress syndrome and severity of multiple organ dysfunction in patients with septic shock. Crit Care Med 2003;31:869–877.
17. Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Am J Respir Crit Care Med 1998;158:3–11.
18. Frantzeskaki F, Armaganidis A, Orfanos SE. Immunothrombosis in acute respiratory distress syndrome: cross talks between inflammation and coagulation. Respiration 2017;93:212–225.
19. Miyashita T, Ahmed AK, Nakanuma S, et al. A three-phase approach for the early identification of acute lung injury induced by severe sepsis. In Vivo 2016;30:341–349.
20. Xue M, Sun Z, Shao M, et al. Diagnostic and prognostic utility of tissue factor for severe sepsis and sepsis-induced acute lung injury. J Transl Med 2015;13:172.
21. Moss M, Bucher B, Moore FA, Moore EE, Parsons PE. The role of chronic alcohol abuse in the development of acute respiratory distress syndrome in adults. JAMA 1996;275:50–54.
22. Sevransky JE, Martin GS, Mendez-Tellez P, et al. Pulmonary vs nonpulmonary sepsis and mortality in acute lung injury. Chest 2008;134:534–538.
23. Sheu CC, Gong MN, Zhai R, et al. The influence of infection sites on development and mortality of ARDS. Intensive Care Med 2010;36:963–970.
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text:
An aldonic acid is any of a family of sugar acids obtained by oxidation of the aldehyde functional group of an aldose to form a carboxylic acid functional group.  Thus, their general chemical formula is HOOC-(CHOH)n-CH2OH. Oxidation of the terminal hydroxyl group instead of the terminal aldehyde yields a uronic acid, while oxidation of both terminal ends yields an aldaric acid.

Aldonic acids are typically prepared by oxidation of the sugar with bromine.  They are generally found in their lactone form, with the ring structure essentially the same as in the original sugar's cyclic hemiacetal form, which is the form the sugar is usually found in.  However, unlike hemiacetals, lactones do not have a chiral anomeric carbon, and they cannot form glycosidic linkages.

Aldonic acids are found in many biological systems, and are the products of the oxidation of aldoses by Benedict's or Fehling's reagents.  Their lactones are key intermediates in the Kiliani-Fischer synthesis of sugars.

Nomenclature of aldonic acids and their lactones is based on replacing the suffix "-ose" with "onic acid" or "onolactone" respectively; hence D-glucose is oxidized to D-gluconic acid and D-gluconolactone.

References

Sugar acids

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The aim of this asset is to increase liquidity for BTCD and place gentle upward pressure on it. Coinomat has done great work with the MMNXT asset. BTCD has much lower volumes and thinner order books, so we're taking a mutual fund as well as market-maker approach. Hopefully using revenues from other assets will inject some liquidity and give us something to work with. Coinomat has very generously donated 100,000 coinomat assets to MMBTCD.


text:
The Elverator
Fish Passage Alliance
Chief Joseph Project
Unsustainable Salmon Populations Issues
06/06/19 03:11 AM Comment(s) By webmaster
Unsustainable Salmon Populations: What are the issues?
Frequently, in the Pacific Northwest, there are media reports regarding the continued decline in the numbers of local salmon species. As an engineering company that pursues scientific validation of our processes and products, we can't help but ask questions and look to what can be done to achieve a viable solution. Initial finger pointing typically focuses on global warming, commercial fishing, hatchery production, nuisance predators, fish passage at dams and the big blue (something(s) not altogether known impacting the ocean ecosystem). Salmon are a valued commodity and to some extent have been attributed a majestic quality. Driven by a primal, instinctive motivation to successfully reproduce, they migrate from rivers to oceans and back to complete their cycle of life. The images of their relentless efforts to forge their way upstream, launching themselves over obstacles, and shouldering their way step after step through the high velocity flows of fish ladders, embodies a strength and determination that is both admired and inspiring. Losing salmon to extinction is a discomforting thought. So, what is really going on? As might be expected, it's a complex set of factors. Not all of the factors are within our control to impact, but for those that are, the single overarching element to embrace is the need to take action and change how and what we are doing now and into the future. What we are doing now is not good enough. Some of the factors include:
Temperature:Global warming is here and real.Temperatures have increased in the oceans and rivers relative to historical records, across all seasons. This has a multi-ecosystem impact changing the dynamic and shifting dominance to favor species most capable of adapting. Salmon like cool waters which they can find during migration if they have the opportunity to swim deep and reach cool mountain streams. Low flows, sedimentation and barriers together with global warming have reduced cool water access.Interestingly, while overall salmon numbers have shown decline, some subspecies are adjusting.Researchers studying the adaptation characteristics of sockeye salmon subspecies populations to increased water temperatures in the Fraser River, British Columbia, Canada have shown that there is hope. The most fit subspecies have broadened their ability to cope.They are finding ways to adapt.Still, it is unfortunate that they need to. We may be limited in our ability to restore water temperatures but providing access to cooler waters, that salmon have historically thrived in, is important to helping to reverse the overall decline in numbers. How can we increase access?
Fish Passage:The Columbia River and its major tributary, the Snake, move huge volumes of water down from the mountains of British Columbia, Washington, Oregon and Idaho out to the Pacific Ocean.There are fifteen major dams on these rivers and fish passage, primarily in the form of fish ladders, is present on the majority of the dams. Tens of thousands of fish pass through these fishways every year.Are they good enough? The fact that one or more subpopulation of almost every salmon species known to inhabit the Columbia River are now listed as threatened or endangered as part of the Endangered Species Act (ESA), the answer is no – not good enough. This brings us back to questions of what do we really know? How are current fishways evaluated? What is the cause of the decline in salmon population numbers?What factors can we influence?What can we do to achieve population sustainability?
Counting Methods: To ensure that commercial fishing is not a significant contributing factor to salmon population declines, the industry has become highly regulated with oversight becoming more and more prominent.This relies in part on annual assessments of fish numbers that are used to establish quotas.
These assessments are based in part on out-migrating smolt metrics of previous years, estimated species annual returns (wild and hatchery-origin), ESA status of potential bycatch, the number of commercial fishing fleet licenses anticipated, and the ecological projections of returns required for species population sustainability. Unfortunately, the accuracy of the estimates and reliability of the current count methods are subject to a substantial margin of error, which is significant in that not just the salmon, but an entire industry, is affected by metrics that lack validated precision. As the numbers of fish continue to decline, it begs the question, can we reliably evaluate salmon population sustainability?
Wild Verses Hatchery Salmon:Researchers have established that wild salmon population viability is impacted by hatchery-origin salmon competing for resources.Ironically, hatchery-origin salmon populations have been generated, in many cases, to mitigate wild salmon losses due to man-made obstacles such as dams, altered water flow, and environmental damage. Hatchery-origin fish are typically marked by clipping the adipose fin, the small fin on the top of the fish behind the large dorsal fin.Commercial and recreational fishing licenses sometimes specify hatchery-origin catch for specific salmonid species and catch-and-release for wild salmon. Unfortunately, identification of an adipose clipped fin requires visualization, which is a secondary action relative to the initial catch.The consequences of the initial catch can impact subsequent survival. Catch and release survival estimates vary greatly depending on method of capture and time-associated definition of survival (immediate verses survival to achieve reproduction).In 2009 the Washington Department of Fish and Wildlife (WDFW) initiated a Commercial Selective Gear Implementation Program to encourage better, sustainable, gear solutions for selective harvest of hatchery-origin fish . The technologies and techniques applied sought to limit handling, reduce gear-associated injury, stress and air exposure. Adopting different selective harvest gear such as these has the potential to improve fish welfare, revitalize fishing communities and facilitate more sustainable wild salmon populations and commercial fisheries. Actions worth taking.
Predators:Nuisance predators are a challenge to consider on many levels.Whether we are talking about sea lions, seals or orca in search of a dwindling food supply near dams, locks and fishing operations there is controversy and confusion.If we all agreed that ensuring sustainable salmon populations had priority, ranking first over all others, then the action plan would be clear.But, the public loves sea lions, seals and orca and they serve a vital role in the ecosystem.Salmon are their natural food source.Like many salmon, orca numbers are declining and are now listed as endangered in some locations.We created barriers, obstructions, and collectively guided fish for our own benefit. Now, these predators are simply using our ingenuity for their own benefit.These predators have adapted, going where the salmon, their food, is found. This raises a number of ethical questions. Do we have the right to remove these salmon predators? If we do or if we don't, how can we ensure their safety? Where is the right place to move them and how might that impact them on a social, behavioral and at an intra-species community level? Restoration plans for salmon must take into account the complexity of the ecosystem in which they live including their prey and their predators.
Assessment:Temperature, stress, predators, flow conditions, fish passage energy expenditures, and hatchery-origin competition for resources all impact wild salmon survival. Most would agree that all these factors are valid, however, the degree to which meaningful evaluations of survival are conducted relative to these factors is a question.At fishways, if survival is evaluated at all, most only look to see if the fish completed passage through the fishway, over the last step of the fish ladder. Longitudinal survival evaluations that consider the impact of fish passage relative to reproductive sustainability are rare. Our current monitoring methods provide only a key-hole view of survival. Fish counts are routinely achieved via visual monitoring through a fish window or via video of fish swimming up fishways. These counts are subject to human error, fallback, missed fish in night hours and count delays. When speaking about survival we must place context into the discussion. Survival through a fishway verse sustained migration survival to the spawning grounds is an important distinction when it comes to realizing sustainability goals.
Context: This lack of full-context, forward thinking has been a problem from the start.Over the course of nearly 50 years, only 96 peer-reviewed articles have been identified that focus on fishway evaluations, and as noted by the researchers who reviewed the scientific literature, very little has changed in that time-period [4].Fishway design was originally dominated by an engineering-focused approach with little consideration given to fish behavior, swim ability, fish motivation, habitat viability or sustainable ecology.If a fish reached the top of a fishway alive, fish passage was deemed "successful" and "sufficient".Of the 96 publications, only seven examined the relationship between passage and fish physiology.Thankfully, this has begun to change.More recent studies have described biochemical markers and monitoring devices which may provide useful physiological evaluations of fish passage success linking passage to sustainable survival.Silva et al., state that "Designing efficient fishways, with minimal passage delay and post-passage impacts, requires adaptive management and continued innovation".They stress the importance of looking beyond old ways of thinking, and pointing toward improved collaboration, information sharing, and method standardization as being needed to address the erroneous view that fish passage is largely a proven technology .
Process: Just because it is the way we have done things for 50 years doesn't make it the best way for the fish.There are new, innovative fish passage technologies that can positively impact sustainable species survival.Traditional fish passage solutions have primarily been viewed as engineering challenges and endeavors in concrete. This we need to change.Fish passage is for fish; we need to look to the needs of the fish when considering design, development and fish passage installation. This requires we shift the paradigm in fishway engineering to embrace innovation and consider the fish first. Recent publications by a number of prominent fish biologists have lent voice to the fish perspective on designs for fish passage solutions .Given the lack of evaluations and standardization of fish passage assessment, the lack of precision in counting, and the repetition of use of outdated fishway designs, it is not surprising the erroneous view that traditional fishway design are effective persists.The monumental lack of evaluation means we cannot rely on fish passage data as justification for or against use of a fishway design. Once again, if we consider the fish perspective the picture becomes clearer. If the traditional fishways currently installed were doing their job well enough there would be no issues or questions about sustainable salmon populations.But there are issues and questions. The salmon populations are, in large part, declining. Fewer numbers of reproductively capable salmon are reaching the spawning grounds. Sustainability of salmon species populations is a very real and challenging concern.
Take-Action: Global warming, commercial fishing, hatchery production, nuisance predators, and fish passage at dams are important sustainability considerations.We can influence all of them if we are creative, innovative, and committed.First, however, we must be progressive and move beyond old ways of thinking.Henry Ford once said: "If you always do what you've always done, then you'll always get what you've always got." What we have got is not good enough. For salmon sustainability, changes are clearly needed.Changes are opportunities to improve, to do more better. Now is the time to take-action, to think creatively from unrestricted viewpoints, and embrace adaptive, innovative solutions that positively impact salmon population sustainability.If we adjust our mindset, acknowledge the factors we can impact and actively integrate science and new engineering technologies viable solutions will follow.
Janine Bryan, PhD
Whooshh Innovations
VP Biological and Environmental Sciences
1. Eliason, E.J., et al., Differnces in Thermal Tolerance Among Sockeye Salmon Populations. Science, 2011. 332: p. 109-112.
2. Wild fish conservancy, 2016 Washington Coastal Restoration Initiaitive Report Evaluation of Pound Nets as Stocl-Selective Fishing Tools- Year 1. 2016.
3. Wild fish conservancy, Commerical Fish Traps a Way Forward for Fish and Fishermen. 2017, Wild Fish Conservancy. p. 1-2.
4. Roscoe, D.W. and S.G. Hinch, Effectiveness monitoring of fish passage facilities: historical trends, geographic patterns and future directions.Fish and Fisheries, 2010. 11(1): p. 12-33.
5. Prystay, T.S., et al., The influence of water temperature on sockeye salmon heart rate recovery following simulated fisheries interactions.Conservation Physiology, 2017. 5: p. 1-12.
6. Raby, G.D., et al., Validation of reflex indicators for measuring vitality and predicting the delayed mortality of wild coho salmon bycatch released from fishing gear. Journal of Applied Ecology, 2012. 49: p. 90-98.
7. Burnett, N.J., et al., Burst Swimming in Areas of High Flow: Delayed Consequences of Anaerobiosis in Wild Adult Sockeye Salmon.Physiological and Biochemical Zoology, 2014. 87(5).
8. Silva, A.T., et al., The future of fish passage science, engineering and practice. Fish and Fisheries, 2017: p. 1-23.
9. Cooke, S.J. and S.G. Hinch, Improving the reliability of fishway attraction and passage efficiency etsimates to inform fishway engineering, science and practice. Ecological Engineering, 2013. 58: p. 123-132.
10. Williams, J.G., et al., Thinking Like a Fish: A Key Ingredient for Development of Effective Fish Passage Facilities at River Obstructions. River Research and Applications, 2012. 28(4): p. 407-417.
Fish Ladders
Pier 91 – Port of Seattle, Bldg 156
2001 West Garfield Street
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© 2019 Whooshh Innovations Inc


The group of individuals that formed Advanced Accessory Concepts have a combined 50+ years' experience in the design, development and cost effective manufacturing of unique accessory components. Our goal? To improve and enhance your personal experience and overall vehicle performance. We are enthusiasts and it shows in our work. Across all brands we strive to offer products that perform beyond consumer expectation in both fit and finish, resulting in higher quality accessories and focused customer service. We can also be your turn-key resource for contract private label manufacturing, working to meet your exacting specifications and achieve target costs to meet your goals and objectives. As a small privately owned company we can respond quickly to your needs for accelerated schedules and reasonable volumes that often times a larger corporation simply cannot provide! Occasionally a problem may arise with one of our products ... it's rare but it happens! If you ever have an issue with any of our products, please don't hesitate to call us! A real person will pick up the phone and help. At the core of every product we design is American ingenuity and product integrity. We will continue to do our best to lead in the marketplace with unique offerings for you, our valued customers!


text:
NATIONALNEWSPeople Daily
Matatu owners vow to reject BRT plan
Mathew Ndung'u January 21, 2019
Kiambu Governor Ferdinand Waititu joins matatu owners in a dance at Ruiru stadium on Saturday. Photo/MATHEW NDUNG'U
Mathew Ndung'u and Oliver Musembi @PeopleDailyKe
Matatu owners from Kiambu, Murang'a, Laikipia, Nyandarua, Kajiado, Nairobi and Machakos counties have vowed to reject government's scheme to introduce bus rapid transit (BRT) system aimed at decongesting roads.
The government says the first batch of the BRT vehicles, which had already been identified in South Africa, is expected to arrive this month, maintaining it will first launch five BRT corridors in Nairobi to reduce traffic congestion in the capital.
On the contrary, investors in the matatu industry want the procurement of the said buses deferred to allow for adequate preparations.
Making the declaration in an event held at Ruiru stadium on Saturday, the transport sector stakeholders decried that the government did not follow due process in enacting the move.
Led by Matatu and Boda boda Operators Federation chairman Kushian Muchiri, the investors raised concerns that the government has been formulating transport sector-related policies withoutconsultation, adding that this was hurting their investment.
"The incoming buses are not meant to decongest the capital. Instead, some rogue parties involved in the importation are pursuing their selfish interests. They are importing the buses at Sh25 million while the same capacity bus, assembled in the country is going for less than Sh10 million," claimed Muchiri.
They rejected the phasing out of 14-seater matatus saying it will increase the rate of unemployment. The investors from six matatu owners associations merged to form a united front in an effort to fight BRT scheme by the government as well as the phasing out of 14-seater matatus.
Kiambu Governor Ferdinand Waititu who was installed as their patron said 90 per cent of public transport in the county was being conducted by 14-seater matatus terming it irrational to phase them out as they have employed more than 10 million Kenyans both directly and indirectly.


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Inspiring educators
Home → Career Exploration → Inspiring educators
Douglas County teachers take part in Summer STEAM Institute
With the success of her school's first Family STEAM Night last year, Tri City Elementary teacher Tammy Bryant was inspired to share her experience with other educators in Douglas County.
Bryant, who teaches first grade, had attended the 2017 Summer STEAM Institute organized by the Umpqua Valley STEAM Hub and later that year helped bring a variety of science, technology, engineering and math activities to campus for a night of family fun and learning.
Local teacher Tim Weber (left) prepares to launch a rocket created during the Project Based Learning with Rocketry workshop.
For this year's STEAM Institute, Bryant offered to facilitate the Family STEAM Night workshop, explaining to colleagues how they too could engage their students, parents and community members in new ways.
"The opportunity for parents and kids to work together on those activities was so interesting to watch as a teacher," she said. "It was enjoyable for every member of the family; everyone really seemed to get a lot out of it."
Family STEAM Night was just one of many workshops available to educators over the summer at Umpqua Community College. The sessions were held from Aug. 13-16 and were open to anyone interested in expanding STEAM education. Participants also had the chance to earn professional development credits.
"We were excited to once again offer these training programs meant to inspire teachers who can then go on to inspire students," said Gwen Soderberg-Chase, DCPSS and Umpqua Valley STEAM Hub director. "We're grateful to all of our partners for making the Summer STEAM Institute possible."
Along with Family STEAM Night, workshops included: Let's Explore Our Place! The Oregon Explorer Digital Library; Oregon Connections; Math in Real Life; Collaborative Lesson Plans with Lending Library Resources; Demystifying NGSS; Mastering the World of Vernier Technology; Telling Spatial Stories About Our Place Using GIS; GLOBE: Place-Based Learning with Students Around the World; Project Based Learning with Rocketry; Put the M in STEM; STEAM in Early Childhood; Bringing Engineering and Design to the Your Classroom; and Explore Integration of Geography in STEAM Education.
Tri City Elementary teacher Tammy Bryant explores the Umpqua Valley STEAM Hub Resource Lending Library.
Participants were also invited to explore the Umpqua Valley STEAM Hub's Resource Lending Library at UCC, which allows teachers to borrow equipment, technology, kits, books and tools for free.
Fullerton IV Elementary School first-grade teacher Amanda Haga participated in the workshop geared toward explaining how to integrate resource lending library equipment into lesson plans. She's excited for the opportunity to help her young students stretch their imaginations.
"At the younger ages, I feel like they're more willing to try things, so fostering that creativity and willingness to try, I think, is more important at the younger ages, so that they keep that mentality as they get older," Haga said.
Chris Lofton is teaching fifth grade at Fullerton for the first time this year and wanted to ensure he was prepared to guide his students to success in the Oregon Assessment of Knowledge and Skills test in science. Exposing students to STEAM learning opportunities, he said, also prepares them for success beyond the classroom.
"We live in an uninformed world, and we want to create students who are more informed," he said. "I think that part of that is discovery and creativity and curiosity. I think STEAM really helps to build that in students and really helps to foster that scientific mind."
Douglas High science teacher Sayer Johnston learned how to build water rockets in a workshop taught by staff from Talent Maker City, a nonprofit in Southern Oregon that seeks to establish Talent as a hub of cultural and economic development.
Lessons from the rocket workshop incorporate trigonometry and physics but can be integrated into lesson plans for several age groups. Participants used soda bottles and other materials to create the rockets, and even employed a 3D printer to create nose cones to enhance aerodynamics. Participants then launched the rockets on the lawns of the UCC campus.
"It's something that's really great for students," Johnston said. "It's got excitement, it's got critical thinking, and it's also got physics and math, so you can really go a lot of different directions with this project."
Soderberg-Chase said the summer workshops will be followed up with ongoing sessions that teachers can attend through STEAM Professional Learning Communities.
"Teachers will continue to share ideas and lesson plans with one another," she said. "It is our vision that all classrooms and learning environments will be filled with quality STEAM activities that are filled with hands-on, minds-on learning."
Next year's STEAM Institute will be held Aug. 12-15 at Umpqua Community College.
By DCPSS Webmanager on 09/11/2018 / Career Exploration, Collective Impact, Education Matters campaign, Educator, News, Opportunities, School Years, Umpqua Valley STEAM Hub, Youth, Youth Development / Leave a comment


Bing Overtakes Yahoo for a second place in search.
Just days after the launch of BING decision search from Microsoft already took the 2nd spot in search engine market. This is great result of their advertising money or people just like the new Microsoft search and decision results.
"Microsoft's Bing overtook Yahoo! as the number two search engine in the United States and worldwide Thursday (4th June) according to data from StatCounter Global Stats. StatCounter says that Bing grabbed market share from Google.


What message do you want your business logo design to communicate?
Your logo design is essentially the "face" of your brand, and it should communicate a clear message all on its own. Whether it answers a question, tells a story, identifies a product, or describes a service concisely.
Recently I was invited to speak to a group of high school seniors about logo design. I shared my personal story: how I got started, schools I attended, places I worked, and why I decided to work for myself. They were excited, engaged, and asked lots of questions. I had a lot of fun with them. After speaking, I was invited to meet with each student individually to give them feedback on logo designs for their senior projects.
It doesn't really matter if you're a school student, a new entrepreneur, or looking for a new career, a successful logo design is going to communicate SOMETHING. Ideally, you want it to be intentional and memorable.
Of the student logo designs I reviewed, a few really stood out. The logo designs that told a story – whether about the service offered, or with a sense of humor – will be remembered easily.
A clear message about your business will help make your logo design successful and memorable.
Now, let me tell you a little bit about my upcoming ecourse, Learn2Logo & Launch Your Brand. I've spent the better part of a year researching, writing, reading, and learning how to create an ecourse all about logo design. I've waffled, stressed, put it down, picked it up, hid from it, and hid it away– all in the name of fear. But I can't let that stop me from sharing the topic I love, and finally complete and launch my ecourse in 2016.
Learn2Logo is all about the research and decision-making that is the foundation of creating a custom logo design–from what your business is about, to what you sell, to who you serve, and why. You'll learn about fonts, colors, shapes, plus mood boards, and even sketching ideas. And I've made sure to structure the ecourse to accommodate people who want to be creative, as well as those who want a professional to complete the design process.
I've put together a Logo Design Success Toolkit that contains some of the resources I've developed and collected for the ecourse, and I'd love to share it with you. Click on the button below to sign up and I'll send it to you. If you find it useful, share the knowledge with your friends and colleagues!


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After nailing a call for a pullback in June, Canaccord's Dwyer predicts another S&P 500 slide
Canaccord Genuity strategist Tony Dwyer has been bullish on the U.S. stocks in recent years, predicting after rising more than 23% in 2019, the S&P 500 will reach 3,350 by the end of 2020, a more than 8.3% increase from Tuesday's close.
But Dwyer has also made intermittent calls for pullbacks, including an accurate call on April 30 for a minor retrenchment in the S&P 500 index
SPX, +0.77%
to precede a resumption of its upward trajectory. Indeed, from the close of trade on April 30, through June 30 the S&P 500 declined 6.9%, before rising to record highs in late July and again in recent weeks.
He is once again predicting an S&P 500 retracement. "Our core thesis remains positive, with low inflation, an easy Fed, a re-steepening of the yield curve, slowing but positive growth, better-than-expected [earnings per share] and valuation expansion, although the tactical backdrop suggests a minor correction over the near term," Dwyer wrote in a Tuesday note to clients, referring to a widening gap between interest rates of varying maturities that had flattened in recent months, often viewed as an accurate predictor of coming economic weakness.
The yield of the 10-year Treasury note
TMUBMUSD10Y, +0.00%
yield for example has risen to 1.874%, from 1.691%, withe differential between the benchmark debt and the 2-year Treasury note
at 1.626% widened to about 24 basis points from 17 basis points at the end of October, FactSet data show. Meanwhile, the S&P 500, the Dow Jones Industrial Average
DJIA, +0.80%,
and the Nasdaq Composite Index
COMP, +0.73%
have established fresh records since stumbling during the summer.
"The recent string of new all-time highs in the major equity indices have pushed our indicators further into the extreme overbought territory that led to the [pullback in June]," he added.
These indicators include: the percentage of S&P 500 constituents above their 10 and 50-day moving averages are on the decline; low levels of implied volatility as measured by the Cboe Volatility Index
VIX, -7.66%
and increased investor optimism as measured by the percentage of Investors Intelligence newsletter writers expressing bullish sentiment.
Meanwhile, "Our trusty 14-week stochastic indicator is back to an extreme overbought level of 99 on a scale of 0 to 100," Dwyer wrote.
"Such a level of overbought in a bull market isn't a negative thing, it's just a sign that it is time for a breather."
"The S&P 500 has reached into a level of overbought territory that suggests a period of consolidation and increased volatility may lie directly ahead," He added. "That said, our still positive core fundamental thesis, current valuation level and history of year-end ramps suggest any weakness should prove limited and temporary and provide an entry point for a move toward our 2020 target of 3,350."
Tagged: a, Call, Canaccords, commodity, Dwyer, equity markets, financial market news, June, n, nailing, north america, predicts, Pullback, Slide, united states
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Standing in front of hundreds of baking professionals this week, I was sharing about my EatBread90 journey. Many of them were there to see if I really ate a loaf a day.
Did you actually do it? What happened? Did you eat white bread as well? There's no way you're that weight! How can you not gain weight with this much bread? You must be really young to not gain all this weight.
The questions after the presentation were endless. This is what I wanted. I secretly planned the aftermath of this experiment. Which is, to get bread to be the topic of healthy eating again. And I did it. I sparked the idea in people's minds that bread could possibly be healthy!
So why did I really reveal my weight in journey on stage?
Well, because I wanted to answer the varied questions about how bread can be healthy with just pictures. You see, if bread is the villain that everyone paints it to be, I would have gained a lot of weight. At 1 lb of bread a day, about 1,400 calories, I would have at least gained at least 30 lbs in 90 days right? These pictures pretty much said it all. The idea that eating bread makes you gain weight is a myth.
Now it's time to take this experiment to the next level. Can you lose weight with bread in your diet? For the next 90 days tune in and read my blogs to see if I get lucky with this experiment.
Carbs are not bad for you. Based on a 2,000 caloric intake, a daily intake of 300g worth of carbohydrates is recommended. Everyone should at least eat 120 – 130g each day to meet the minimum required for your brain to function. In bread talk, that's about 3 slices of bread a day.
It's true, if you cut something out from your diet, you will lose weight because your daily habits surrounding that food changes and your consumption becomes more limited. This can be applied universally to all types of food, not just bread.
Why keep bread part of your diet?
Bread should be part of everyone's diet because it is a conveniently nutritious product. If you followed my journey, you would have noticed that I consumed bread that is healthy and easily obtained off the supermarket shelve. You do not need to make these breads yourselves, nor do you have to specially order it.
Why are you eating a loaf? What are you trying to prove?
If this journey said, "I'm eating 3 slices of bread a day, and bread is not killing me" would you believe me? But I ate a pound of bread a day, 12-14 slices, and still, it hasn't done anything bad to me or my weight. Now do you believe me that bread is not bad for you?
How do you eat so much bread in one day?
I've pretty much spaced out my bread eating all throughout the day. Anyone in our office will tell you that I'm stuffing my face with bread all the time. My children will tell you that all I eat is bread at the dinner table. If the clock is ticking, and I'm not in bed, I'm eating bread.
Don't you get sick of eating so much bread?
Never been and never will. My critics, or the Bread Police (they seem to be hanging around in the office) keep asking me that question in hopes of seeing a white flag. I think the answer is pretty simple. I'll never get sick of something I love eating. I've been loving this journey, and will continue to love eating bread, even after 90 days.
My days worth of delicious rolls with a beet salad.
On days six and seven of Dr. Carson's bread diet we were faced with a bread myth we had hoped to bust – the high salt content in bread. It is a known fact that processed foods contain hidden salt. While most of us will not be consuming a pound of bread a day, adding spreads, deli meats, cheese, or soup can push our sodium intake over the limit of what's healthy.
The result could mimic the effects of gluten intolerance than have led many to eliminate bread from their diets. So, let's take a closer look at salt.
Why is there even salt in bread and how much is safe to consume on a daily basis?
Flavor enhancer – I think all of us are familiar with salt's ability to bring out the flavors in baked goods. Sugar seems a little sweeter when salt is added to a recipe. The natural flavors developed during bread fermentation from the yeast and flour are enhanced by the addition of salt. Bread without salt tends to be a little bland.
Dough strengthener – Gluten, the protein in bread, becomes stronger when salt is part of the mix. A stronger gluten structure enables the dough to hold the carbon dioxide gas released during fermentation. This adds volume and texture to your loaves.
Slows fermentation – A slow, steady rise during proofing gives uniform crumb to bread. Faster fermentation can create large air pockets and cause blow outs in finished loaves.
Extends product shelf life – Salt is a known preservative. It increases shelf life of loaves by decreasing staling. Salt is hygroscopic and attracts water from the environment keeping bread softer longer than bread baked without salt.
When we talk about salt, sodium chloride, and our health, it is the sodium that we need to be aware of. Food labels list sodium rather than salt. 2.5 grams of salt contain 1 gram of sodium. Sodium is a known part of salt, but did you know it is also in Monosodium glutamate and baking soda? If you are not looking at every food label you could easily consume more sodium than you need. The World Health Organization recommends under 2 g/day sodium (5 g/day salt) in adults.
Too much sodium intake makes your body hold water. Holding water can make you feel bloated or cause swelling. This is known as edema. On the other end of the spectrum too much salt can lead to dehydration. Symptoms of dehydration are extreme thirst, nausea, dizziness, stomach cramps, vomiting and diarrhea. In both cases consuming more water will help flush the excess sodium out of your system.
Back to the myth that bread contains high levels of salt.
The nutritional label on a bag of whole wheat bread by a national bakery lists the sodium at 240 mg per serving. A serving is 2 slices of bread. Not bad. That leaves 1.76 grams for your sandwich meat or marmite spread.
For the average consumer two slices of bread would make up 10% of your recommended sodium intake. Eating a pound of bread a day is another issue. The estimated sodium intake is 1.3 grams without any toppings or dipping into soup. I think it is safe to say that under a normal bread eating situation the salt level is well within the guidelines recommended by the WHO.
The Eat Bread 90 challenge is all about transparency. The pain that Dr. Carson experienced due to high sodium intake definitely caused a shift in her diet.
Do you think we busted the high salt myth or not?
To read more about the function of salt in baking, go here.
To learn more about salt and your health go to the WHO web site and this article by the Harvard Medical School.
Weigh-in time again! As these two pictures clearly show, yes, you can maintain or even lose weight on a bread diet. Of course, exercise, the other food you eat, and how much you eat is important. That's why I post my daily food and calorie logs, so you can see just how possible it is. Now if you will excuse me, I have some bread to go eat.


text:
Weinstein's Move 'The Road' to November 25
The first question that came to mind once I was told Dimension Films had decided to move John Hillcoat's The Road — starring Viggo Mortensen and adapted from the Pulitzer Prize-winning Cormac McCarthy novel — from its October 16 release date to November 25 is What about Nine?
Nine, the musical adaptation of the stage play directed by Rob Marshall (Chicago) was already slated for November 25, is a Weinstein feature and is also a heavy Oscar favorite. Of course, Nine is most likely looking at a puny New York and Los Angeles release in November followed by expanding dates in December, which pretty much alleviates any real kind of competition and proves my query moot.
So, as it stands, the move now pits The Road up against The Fantastic Mr. Fox, Ninja Assassin and Old Dogs with Disney's The Princess and the Frog also getting a limited release with plans to expand nationwide on December 11.
Based on the trailer (included in this post) it would appear The Road and Ninja Assassin are going for the same audience even though the material differs drastically, which does make the move slightly curious with Dimension and the Weinstein Co. doing everything they can to add more and more money to their coffers.
In an article at Variety, Ali Jaafar says the studio is planning a multi-layered marketing operation for The Road, targeted at both fans of McCarthy's book and audiences fascinated by the more ghoulish aspects of the tale such as the hordes of cannibal killers roaming the barren landscape. If you ask me they are overestimating audience anticipation for the "ghoulish" aspects and forgetting the fact everyone knows who Cormac McCarthy is following No Country for Old Men and should really be pushing that angle more than anything.
The Road is set to be released in 1,200 to 1,500 locations.
Early reviews for the film out of film festivals range from excited to bored, and everything in-between. You can check out said reviews by clicking on any of the links below and I have five clips from the post-apocalyptic nightmare right here should you be so inclined.
This is London
New to Stream: Crackle's November 2020 Movie & TV Lineup
Next month includes the Crackle AVOD Exclusive Feature Blood and Money
2019 Sundance Film Festival Announces Programming with 112 Features
The festival will host screenings from January 24 to February 3, 2019
Weinstein Co./Dimension's Horror Film Polaroid Moves to 2018
The film was set to be released on November 22
The Weinstein Company Moves Up The Founder and Dates Lion
The former stars Michael Keaton as McDonald's founder Ray Kroc


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San Francisco 49ers Mock Draft Monday 6.0
San Francisco 49ers Staff
2016 NFL Draft Prospects Linked to 49ers
Take a look at some of the names being associated with San Francisco's seventh-overall pick.
There are just 10 days remaining until the 2016 NFL Draft. "Mock Draft Monday" gained plenty of intrigue last week following a blockbuster trade between the Tennessee Titans and Los Angeles Rams.
The details of the deal are as follows: The Titans sent the Rams the No. 1 overall pick along with a fourth-rounder (No. 113) and a sixth-round pick (No. 177). In return, Los Angeles will give up its first-round pick (No. 15), two second-rounders (Nos. 43 and 45) and a third-round pick (No. 76). Additionally, the Titans will receive the Rams first- and third-round picks in 2017.
With that, here's the mock-draft fallout with a new team sitting at the top of the order. The following are expert predictions for how the San Francisco 49ers will use the seventh-overall pick.
Matt Miller, Bleacher Report: DeForest Buckner, DL, Oregon
"The 49ers miss out on the top two quarterbacks but land a blue-chip defensive lineman. It's Oregon Ducks in back-to-back first rounds for the Niners, but new head coach Chip Kelly won't mind that."
Daniel Jeremiah, NFL.com: Jared Goff, QB, California
Bucky Brooks, NFL.com: Ronnie Stanley, OT, Notre Dame
"They take Stanley and put him at right tackle to help the team get back to being solid up front."
Charles Davis, NFL.com: Buckner
"Buckner is an excellent prospect who has plenty of size, power and movement skills. Buckner uses his long arms to keep blockers at bay and to get upfield and make plays."
Charley Casserly, NFL.com: Stanley
"Tough choice with DeForest Buckner (DE) on the board, but OT is a greater need"
Lance Zierlein, NFL.com: Stanley
"The right tackle spot requires immediate help. Stanley would add terrific pass protection, as well as the type of athleticism that is a perfect fit for Chip Kelly's rushing attack."
Chad Reuter, NFL.com: Paxton Lynch, QB, Memphis
"It will be tough for the Niners to pass on a mobile, strong-armed prospect like Lynch. Chip Kelly had a lot of success with Nick Foles in his early days with the Eagles, so there's no reason the same can't be had with Lynch."
Rob Rang, CBS Sports: Buckner
"The 49ers could opt to rebuild their once proud defense, pairing Buckner with Chip Kelly and his former Oregon teammate Arik Armstead, San Francisco's top pick a year ago. At 6-7, 290 pounds, Buckner is an ideal five-technique defensive end for San Francisco's scheme."
Dane Brugler, CBS Sports: Myles Jack, LB, UCLA
"There are several teams who will not consider Jack due to his knee injury, but there are also teams who will see the linebacker as worth the risk. And San Francisco might be one of those teams."
Pete Prisco, CBS Sports: Lynch
"I stay with a quarterback in this spot. Lynch is raw, but there is a lot to like. Once he fixes his footwork, he will be much better."
Will Brinson, CBS Sports: Buckner
"They can pair Buckner with Arik Armstead and hope the two defensive players from Oregon can develop together."
Sam Monson, Pro Football Focus: Laremy Tunsil, OT, Ole Miss
"Tunsil is a player people were talking about No.1 overall before the Titans-Rams trade. He can start at RT from Day 1 and has the skills to become one of the league's best tackles."
Chris Burke, Sports Illustrated: Joey Bosa, DE, Ohio State
Eric Edholm, Yahoo Sports: Stanley
Dan Kadar, SB Nation: Buckner
Trey Lance, Brock Purdy Detail Offseason Road to Recovery and Game Readiness
San Francisco 49ers quarterbacks Trey Lance and Brock Purdy are headed into the offseason looking to heal and prepare for the 2023 season.
Arik Armstead, Nick Bosa Among Top Three in 49ers Postseason Sack Records
Defensive linemen Nick Bosa and Arik Armstead sit atop franchise records for most sacks in the postseason.
Nick Bosa, Brock Purdy and Eight More Among 49ers Team Award Recipients
Nick Bosa, Brock Purdy, Fred Warner, Jake Brendel and several other 49ers players were announced as 2022 team award recipients.
49ers Sign 10 Players to Reserve/Future Contracts
The San Francisco 49ers announced they have signed 10 free agents to Reserve/Future contracts.


The Indiana Poetry Society papers (1897-1947; 0.2 cubic feet) is a collection of manuscript poems and letters by members of the Indiana Poetry Society, as gathered by the society president and founder, Eletha Mae Taylor, along with some of her personal papers. Among the personal papers is a composition book containing notations on the study of poetry and literature and spelling/vocabulary lists, music scores, poetry, newspaper clippings and correspondence. The composition book and manuscript book are in fragile condition.
The Indiana Poetry Society was organized as the Indianapolis Poetry Club in October, 1921, by Mrs. Eletha Mae Taylor. Other charter members were Miss Sue Howe, Mrs. Carl Lieber, Mrs. Cora Young Wiles, Mrs. Walter Flandorf, Mrs. Frances Morrison Rabb, Miss Maybelle Chitwood, Mrs. Josephine Duke Motley, Miss Lucille Ballard, Mrs. Carrie Hunt Latta and Miss June Winona Snyder.
This group met each month in the homes of the members while enlisting the interest of others. The organization grew until its membership included more than 250 persons.
In 1927 following affiliation with the General Federation of Women's Clubs, the name was changed to the Indiana Poetry Society. Mrs. Taylor served as the only president. She was also a representative to the American Literary Association.
Officers besides Mrs. Taylor, were Edna Denham Raymond, first vice president; Carrie Abbott Guio, second vice president; Mrs. Ollah P. Toph, third vice-president; Margaret Ann Boyd, secretary; June Winona Snyder, corresponding secretary; Lola F. Echard, treasurer, and Mrs. John Robert Craig, fourth vice-president.
The society, which grew out of a meeting at the home of Meredith Nicholson, had a number of members whose literary work was published. Mrs. Taylor compiled an anthology of Hoosier poetry, and a book comprised of 200 of her own poems. Mrs. Raymond was the author of three volumes. Miss Snyder published a small volume in 1928. Miss Chitwood and her brother, William Hankins Chitwood were also authors. Mrs. Alice Fernold Emerson, representative of the Mitre Press, London, published a small volume. Poems of Mrs. Margaret Bruner were included in anthologies.
No author noted (May 18, 1934). Indiana, Noted for Literary Folk, To Join In National Observance Of Poetry Week. The Indianapolis News, (Indianapolis, Indiana), no page available.
The composition book and manuscript book are in fragile condition.
All materials have been housed in polyester sleeves, acid-free folders, and acid-free boxes. Some clippings containing images of people have been preserved for display purposes, with photocopies made available for research. The composition book and manuscript books are in fragile condition. The manuscript book cover has red rot, so the use of gloves is advised.
MSP 51, Indiana Poetry Society papers, Archives and Special Collections, Purdue University Libraries https://archives.lib.purdue.edu/repositories/2/resources/102 Accessed April 26, 2019.


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With just 1 day left before the first game of the season begins, I will take a look at what I expect to see from teams this season. Last year, we had a few teams take the next step in their pursuit for the Superbowl. Ultimately, the New York Giants took home the trophy. This year, I expect a few different teams to shine, and a new team to take home the trophy.
Brooks Reed will help lead the Texans very deep into the playoffs, as the Texans look to win it all.
Ahhh! August 1st is upon us. The days of July are behind us and the month of August brings us some football. Training camps are going along, and the preseason games will begin soon. With that being said, let's take a look at the NFC, division by division, and let's see what position battles will be taking place during camps and the preseason games.
Atlanta Falcons – The Falcons weakest spot on offense last year was at Right Guard. A position that is not heavily talked about, will turn out to be the main focus for ATL coaches during camp. All eyes will be on the guys who think they can improve the position. ATL switched guys several times last year. They brought in veteran Vince Manuwai, and drafted Peter Konz, to hopefully improve the RG spot. With those 2 in camp, as well as Reynolds and Hawley from last year, expect a feisty competition that will likely go down to the last preseason game. I think Konz is the future at RG in ATL, and could be starting week 1.
Carolina Panthers – The Panthers love having some good RB's. They resigned Williams to a huge contract a few years ago, and also have Stewart, who has also shown he can handle being the starting RB. Heck, if both got hurt, they still have Mike Tolbert who can handle the duties. Williams started most of the games last year, but Stewart saw a lot more snaps. Look for more of the same this year. Williams should start, but Stewart will get more snaps.
New Orleans Saints – The Saints have had a busy offseason to say the least. One thing they can be proud about is the 3 headed monster of Sproles-Ingram-Thomas. Those 3 will all likely get many carries throughout the season. Sproles will likely handle PR duties, and 3rd down duties, and I expect Ingram to have a strong role in the running game. I think Ingram will be the starter, with Thomas getting a few carries here and there, and Sproles being the pesky little guy, he is so great at doing.
Tampa Bay Buccaneers – The Bucs made it clear they wanted another RB, when they drafted Doug Martin. Martin enters TC as the #1 RB, but #2RB, LaGarette Blount, had some success last year as the starter of the Bucs. Martin has looked good in pass protection as well as showing some good hands out of the backfield. Expect Martin to be the starter come week 1, but Blount will probably see some carries as well.