text:
Community-acquired pneumonia as an emergency: time for an aggressive intervention to lower mortality
S. Ewig, A. Torres
European Respiratory Journal 2011 38: 253-260; DOI: 10.1183/09031936.00199810
S. Ewig
For correspondence: ewig@augusta-bochum.de
A. Torres
Community-acquired pneumonia (CAP) is one of the major contemporary acute life-threatening conditions. Short-term mortality reaches 14% (7% if nursing-home residents and bedridden patients are excluded) and long-term mortality reaches 50% within 5 yrs.
CAP and acute myocardial infarction (AMI) have a lot in common with regard to acuity, prognosis, need for risk stratification and early intervention, and secondary prevention measures. The obvious success in the treatment of AMI is due to an effective organisation of pre-hospital care and evidence-based interventions in the hospital within defined timescales.
Less evidence is available about effective strategies to lower short- and long-term mortality in patients with CAP. Nevertheless, it is estimated that ∼30% of hospitalised patients with CAP could be subject to a management approach in parallel to that of acute coronary syndrome (ACS).
Management of patients with severe CAP should be intensified using all elements that have been established in the care for patients with ACS and stroke. One of the main challenges of future research will be to define whether and which additional patients at risk of mortality truly profit from timely and structured interventions. In the meantime, patients at increased risk of death according to clinical prediction tools should also be subject to an aggressive management approach.
Community-acquired pneumonia
Community-acquired pneumonia (CAP) continues to be a frequent infectious condition. With an incidence of three to five cases per 1,000 persons per yr, it is a major acute disorder [1–3]. Incidence rates are up to 10-fold higher in the elderly population [4]. Up to 75% of patients with CAP are hospitalised and of these, up to 10% require admission to the intensive care unit (ICU) [1, 2]. It has been estimated that ∼915,900 cases of CAP occur annually among the elderly in the USA and that approximately one out of every 20 persons aged ≥85 yrs will have a new episode of CAP each year [5]. According to a recent nationwide survey in Germany including all hospitalised patients over a period of 2 yrs, mortality reaches 14%, which is nearly double the figures reported in most studies including selected patients. Mortality reached up to 30% in the elderly and disabled [2]. In accordance with a previous large US study in elderly patients [6], mortality was shown to follow an acute pattern, with most deaths occurring within the first 24 h of admission. This was true across all risk classes, even the lowest one. CAP is also associated with considerable excess mortality after recovery from the acute episode, reaching 50% within 5 yrs after hospital discharge. This holds true also after adjusting for age and comorbidity [7–10]. Due to general demographic trends, at least in Western societies, case numbers of CAP are expected to increase considerably [11–13]. Therefore, the relevance of CAP as a major public health challenge is clearly increasing steadily.
Despite these impressive figures, no effort has been made to organise a major public health effort in order to reduce short- and long-term mortality. Recent authoritative guidelines have, appropriately, focused on the improvement of key processes of care, including severity assessment, selection of treatment setting and differential empirical antimicrobial treatment [14–16]. However, recommendations remain aimed at individual care, and it appears that there is little attention paid to the real potential of preventing excess mortality. As a result, pre-hospitalisation times remain inadvertently long and timescales of interventions largely undefined. Moreover, apart from a recommendation for vaccination, no advice is given for the post-hospitalisation period.
The following statement is guided by the notion that CAP should be recognised as one of the major contemporary acute life-threatening conditions requiring a corresponding public health effort to improve outcomes. In fact, much can be learnt from the lessons of cardiovascular disease management. The obvious success in the treatment of acute myocardial infarction (AMI) is due to an effective organisation of pre-hospital care and evidence-based interventions in the hospital within defined timescales. CAP and AMI have much in common with regard to acuity, prognosis, need for risk stratification and early intervention, and secondary prevention measures. Evidently, these parallels are limited to the structure of management of an acute condition with high mortality and considerable potential for life-saving interventions. Moreover, less evidence is available about effective strategies to lower short- and long-term mortality. However, with these limitations in mind, nearly every element in the management of AMI could and should find its counterpart in the management of CAP.
Up to the middle of the last century, pneumonia was recognised as a major life-threatening condition. Mortality of pneumonia was very high, reaching 100% in elderly patients with pneumococcal bacteraemia [17]. Prognosis of pneumonia complications, such as abscess formation or empyema, was poor. Standard treatment was not available, and interventions such as serum therapy yielded conflicting results. Thus, pneumonia was a regarded as a leading public health problem [18].
With the emergence of effective antimicrobial treatment, mortality of pneumonia was reduced dramatically, and the fear of pneumonia and its status as a public health emergency have been lost [18]. Pneumonia, as well as infectious diseases as a whole, were increasingly regarded as solved problems, and attention shifted to modern conditions limiting life expectancy, such as cardiovascular diseases and malignancies.
In the meantime, infectious diseases have been rediscovered as major problems, and despite considerable advances in diagnosis and treatment, infections are at the top of the agenda of conditions urgently in need of new approaches and solutions [19]. Lower respiratory tract infections (LRTIs) in particular are the leading cause of hospitalisations for infectious diseases [20].
In contrast, progress in the treatment of cardiovascular diseases is unequivocally impressive. The management of acute coronary syndromes (ACS) is perhaps one of the most obvious examples. The natural history of this acute, life-threatening condition is associated with high mortality, yet after decades of intensive efforts, in-hospital mortality does not exceed ∼5% [21, 22]. This major progress is due to a fabulous interaction of basic research and clinical application, resulting in a myriad of excellent randomised studies with meaningful conclusions. In addition, and not least, cardiologists have succeeded in raising the awareness of ACS as an emergency with a major therapeutic life-saving potential. This was possible due to the background of convincing data showing that "time is muscle". If every minute matters, evidently, emergency medical systems linked to hospitals capable of providing a rapid diagnosis and performing the relevant interventions effectively and in time had to be created. With the identification of patients with non-ST elevation ACS (NSTEACS) at increased risk of mortality with the use of the biomarker troponin, subsequent major progress in risk stratification was made.
As a result, a generally accepted and increasingly sophisticated management algorithm continues to contribute to optimal treatment of patients with ACS. Finally, distinct interventions to identify possible complications in- and outside the hospital, as well as to address risk factors for atherosclerosis, have been applied, and these further reduce mortality from cardiovascular diseases. Similar efforts have been made in the field of stroke, following many of the key elements of the structure of ACS management ("time is brain") [23].
COMPARISON OF INCIDENCE AND MORTALITY RATES OF ACS AND CAP
The annual incidence of ACS in Europe is around one case per 80–170 persons per yr. The incidence of hospital admissions for non-ST elevated myocardial infarction (NSTEMI) has been shown to be in the range of three cases per 1,000 persons per yr in Europe, with variations among European countries. In the UK, the incidence of ST elevated myocardial infarction (STEMI) is around six cases per 1,000 persons per yr in males and two cases per 1,000 persons per yr in females.
The global mortality rate of STEMI is ∼40%, with two-thirds occurring before hospital admission. Overall hospital mortality of STEMI is around 6–7% and that of NSTEMI is around 4–5%, but at 6 months, their respective mortality rates are similar. Mortality rates of STEMI tend to be ∼3% higher in registries than in clinical trials. Long-term death rates in NSTEMI are even higher than in those with STEMI (11 versus 7%) [21, 22].
Thus, incidence rates of pneumonia requiring hospitalisation are comparable to that of NSTEMI and STEMI. The excessive pre-hospital mortality is unique for STEMI. Pre-hospital mortality of pneumonia is unknown but is probably minimal; mortality of patients with mild pneumonia treated outside the hospital is low (1–3%). However, in-hospital mortality of patients with hospitalised CAP including all risk groups is ∼14%. If patients admitted from nursing homes and bedridden patients are excluded, it is still ∼7%. Nursing-home residence and a bedridden condition increase mortality two- and three-fold, respectively. Studies in elderly patients (usually >65 yrs of age) reported a mortality of ∼30% [2].
The risk of mortality is highly dependent on pneumonia severity. This can be assessed using clinical prediction tools. The Pneumonia Severity Index and the CURB-65 (confusion, urea >7 mmol·L−1, respiratory frequency ≥30 breaths·min−1, systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg, and age ≥65 yrs) or CRB-65 (confusion, respiratory frequency ≥30 breaths·min−1, systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg, and age ≥65 yrs) all result in predictions in a three-class pattern. Patients at low risk have a mortality of 1–3%, at intermediate risk of 8–12% and at high risk of up to 35% [2, 24, 25]. Mortality rates of patients with severe CAP admitted to the ICU reach 30% [26].
These mortality figures seem impressively high. Mortality rates of hospitalised CAP patients judged to be at intermediate risk still parallel mortality rates in patients with STEMI. Even more striking is the high excess mortality rate in survivors of CAP, reaching ≤50% within 5 yrs [7–10].
Following a 5-yr nationwide quality-assurance programme in Germany, no reduction in mortality could be documented [27]. The true potential to reduce mortality rates of CAP is unknown. In general, the incidence of pneumonia is age dependent, with the highest incidence at the extremes of age, and it is obvious that mortality rates are mainly driven by age. Even so, ∼75% of patients >90 yrs of age survive their pneumonia episode [2]. However, ∼85% of patients who die in hospital have not previously received ventilator support [2]. Thus, it appears that a large proportion of patients who die from CAP are judged to have CAP as a terminal event of a disabling condition.
In view of these data, the potential to reduce mortality from CAP has to be assessed in patients without restrictions in treatment escalation at increased risk according to clinical prediction tools. Probably the greatest potential to decrease mortality is in patients at increased risk but without major criteria of severity at their first presentation. Given that ∼50% of patients with CAP are hospitalised and that around two-thirds of hospitalised patients are at intermediate or high risk, an estimated 30% of hospitalised CAP patients are subject to interventions to potentially improve outcome.
COMPARISON OF MANAGEMENT STRUCTURES OF ACS AND CAP
The structure of the management guidelines of ACS follows a strict risk stratification (table 1) [21, 22]. The symptom of acute chest pain constitutes the working diagnosis of an ACS. This working diagnosis is substantiated by a 12-lead ECG and the biomarker troponin. ACS is then further divided into three risk groups: 1) STEMI (highest risk); 2) NSTEMI, with ST or T abnormalities and/or troponin elevation (high risk); and 3) NSTEACS, without troponin elevation (i.e. unstable angina after exclusion of other reasons of chest pain; low risk). Thus, ECG and the biomarker troponin are the mainstay of risk stratification when ECG does not show ST-segment abnormalities. Low risk is only established after repeated determination of ECG and troponin.
Table 1– Comparison of the structure of management of acute coronary syndrome (ACS) and community-acquired pneumonia (CAP)
Interventions are recommended accordingly as urgent in STEMI, early (<72 h) in NSTEMI with troponin elevation or elective in unstable angina.
The Global Registry of Acute Coronary Events (GRACE) risk score allows calculation of the individual risk of AMI and in-hospital death and after 6 months (www.outcomes.org/grace).
Comparing the management structure of ACS and CAP according to current guidelines, striking similarities but also important differences are obvious. Symptoms of fever, cough and/or dyspnoea result in the working diagnosis of a LRTI. The presence of pneumonia is confirmed by radiography. Thus, ECG and radiography are diagnostic for the most important differentiation within the working diagnosis (i.e. AMI versus non-AMI and CAP versus non-pneumonia). In contrast, whereas the diagnosis of AMI is equivalent to the most severe condition within ACS, assessment of severity has yet to follow the diagnosis of CAP.
At present, risk stratification of CAP identifies three groups at risk (low risk: amulatory treatment; intermediate risk: hospitalisation; high risk: ICU or intermediate care) [14–16]. However, it is clear that a subgroup at intermediate risk (and a very small one at low risk) is at risk of early deterioration and actually at high risk of death. This subgroup should be subject to monitoring and a higher level of intervention. There is an urgent need for the identification of predictors of this subgroup. If identified, this would be the parallel group to NSTEMI.
The definition of severe pneumonia is straightforward in patients with so-called major criteria (requirement for mechanical ventilation and/or vasopressors). It is less clear how to define severe pneumonia in patients without these criteria. At present, severe CAP is best defined as requirement for ventilator support and/or fluid resuscitation and/or treatment for severe complications [28].
The role of biomarkers in CAP differs from that in ACS, in that troponin identifies patients at increased risk (i.e. NSTEMI versus unstable angina, or a condition other than ACS) whereas procalcitonin identifies patients at low risk (i.e. patients with LRTI not requiring antimicrobial treatment) [29]. Furthermore, the structure is different in that clinical scores have less impact on patient management in ACS than in CAP. This is because all patients with ACS are considered to have to be monitored until a definite diagnosis is made, and because the biomarker troponin determines both diagnosis (of NSTEMI versus unstable angina) and risk stratification. The role of biomarkers in risk stratification of CAP is less well established, whereas clinical scores yield excellent predictions of the risk of death. Current data indicate that a combination of a clinical score with a biomarker will yield the best predictions [30, 31].
Notably, the recent development of a highly sensitive troponin-T assay represents a further refinement in the identification of patients with NSTEACS at increased risk, with high precision even in the 99th percentile [32, 33].
COMPARISON OF MANAGEMENT STRUCTURES OF STEMI AND CAP
The hallmarks of the management of STEMI include the following six issues (table 2).
Table 2– Comparison of the structure of management of ST elevated myocardial infarction (STEMI) and severe community-acquired pneumonia (CAP)
First medical contact and emergency care flow
The first medical contact and emergency care flow is thought to the shorten time from suspected diagnosis to hospitalisation, which is particularly relevant in AMI due to the high pre-hospital mortality of ≤50%. The crucial issue is to establish an emergency medical system linked to capable hospitals.
A working diagnosis of AMI has to be established as quickly as possible based on history, clinical symptoms and a 12-lead ECG: all of which are rapidly available measurements without relevant risk of a diagnostic delay. Clinical chemistry is not awaited in order to save time.
No emergency medical system is established for severe CAP. The emergency care flow is similar in severe CAP; however, the relevance of making a rapid diagnosis is not generally settled, particularly in those patients without septic shock.
Pre-hospital and early in-hospital care
A working diagnosis and specific treatment is made outside the hospital if rapid hospitalisation is not within reach. Most patients will receive reperfusion therapy by percutaneous coronary intervention and/or fibrinolysis within a time frame of ≤2 h. A door-to-needle time of <30 min and door-to-balloon time of <2 h are defined targets that have to be met.
Possible acute complications (pump failure and shock, mechanical complications, arrhythmias and conduction disturbances) are addressed and prophylactic treatments are listed.
To date, even parts of the guidelines for severe sepsis and septic shock are not generally imported in guidelines for severe CAP, and even less in general practice. A major issue is the incorporation of early goal-directed therapy in patients presenting with CAP and severe sepsis. There is major evidence that clinical failures are related to severe sepsis [34] and that prognosis of patients with septic shock worsens with every hour of delay in appropriate antimicrobial treatment [35], and the importance of rapid initiation of appropriate antimicrobial treatment parallels that in acute bacterial meningitis [36].
No exact door-to-antibiotic timescale has been defined in guidelines or settled in clinical practice. The same is true for the initiation of aggressive fluid resuscitation in severe CAP with severe sepsis [37]. The evidence in favour of a door-to-antibiotic time in patients without septic shock is less clear [38–42]. It probably heavily depends on the populations studied. Also, most studies are heavily underpowered to find a small but relevant difference in mortality. Some authors have even raised concern about such a timescale because of the risk of overtreatment [43–45]. However, overtreatment is only a concern if antimicrobial treatment is inappropriately administered prior to a clear diagnosis. In fact, the risk of inadequate diagnosis can be eliminated if there is a pathway that ensures rapid diagnostic work-up. There is a good reason to establish immediate antimicrobial treatment within a defined timescale after the diagnosis of CAP has radiographically been confirmed [38, 39, 46, 47]. However, the exact duration of the timescale is not yet determined. It predictably heavily depends on the severity of CAP at admission.
Management of in-hospital course
This includes all measures against late complications during hospitalisation (thrombosis and embolism, intraventricular thrombus and emboli, pericarditis, late ventricular arrhythmias, post-infarction angina and ischaemia). There are parallels of these in severe CAP, such as pneumonic and nonpneumonic complications. However, they have not been addressed in a comparable systematic way in the guidelines of CAP, and are probable not routinely assessed in clinical practice. As a result, parapneumonic complicated effusions and empyemas are frequently diagnosed with delay.
Risk assessment after AMI
The sequelae of AMI are assessed (myocardial viability and risk of arrhythmia or sudden death). The assessment of risk after severe CAP has only just begun to be studied [48]. Excess mortality, specifically of survivors of severe CAP after discharge from hospital, has not yet been defined, but is suspected to be high in view of the excess mortality of the whole population of CAP survivors. Thus, there is a good reason to start investigations in order to identify tools for preventative interventions in patients at risk of excess mortality after severe CAP.
Rehabilitation and pre-discharge advice
Rehabilitation and pre-discharge advice include psychological and socioeconomic aspects, lifestyle advice and physical activity. Compared with STEMI, it is less clear how and to what extent severe CAP is a consequence of defined psychological and socioeconomic determinants, and even less so how these could be subject to intervention. However, it is possible that this is due to a scientific underestimation of severe CAP as a condition with psychological and socioeconomic implications. Likewise, whereas consequences of limited fitness after myocardial infarction have attracted considerable research and care efforts, no such attention has been paid to severe CAP as a condition possibly limiting physical and psychosocial activities.
Secondary prevention
Secondary prevention targets the following sections: 1) lifestyle habits (smoking, diet, weight control and physical activity); 2) drugs (antiplatelet and anticoagulant treatment, statins, β-blockers, angiotensin-converting enzyme or angiotension receptor blockers, and aldosterone blockade); 3) control of atherosclerotic risk factors (blood pressure, diabetes and lipid profile); and 4) influenza vaccination.
Interventions in lifestyle habits have not been investigated in survivors of severe CAP, although it is quite evident that these would be of equal importance in these patients as in survivors of STEMI. There are no comparable interventions aimed at risk reduction after STEMI using drugs protective to the heart or the control of risk factors for progression of atherosclerosis for survivors of severe CAP, and it is questionable whether such interventions can be defined in the future. The only clear parallel is advice for vaccination, which includes influenza and pneumococcal vaccination in severe CAP.
REQUIREMENTS FOR FUTURE PRACTICE AND RESEARCH
On comparing the management structure of ACS and STEMI with severe CAP, strong parallels are evident. At the same time, several differences hint at important gaps in the current management of patients with severe CAP.
The management of ACS is based on an emergency medical system defining the structure of the first medical contact and emergency care flow. This is based on an awareness of a life-threatening condition, and the importance of predefined treatment algorithms and adherence to defined timescales. No comparable awareness is evident in the care of pneumonia patients, and no comparable emergency medical system has been launched for pneumonia.
The most important gap in the risk stratification of CAP seems to be the lack of predictors for patients at increased risk (i.e. a correlate to NSTEMI with elevated troponin). At present, it appears improbable that a biomarker alone will resolve this issue; instead, a clinical prediction tool or a combination of such a tool with a biomarker are likely to provide a definition in the near future. In the meantime, it is important to keep in mind that an important group of patients apparently at moderate or even low risk are, in fact, at high risk. In the absence of a correlate to NSTEMI with elevated troponin, it seems most practical to provide increased monitoring to all hospitalised patients with increased risk scores. This inherently oversensitive approach is in parallel to the most recent trends in the management of ACS after the introduction of the highly sensitive biomarker troponin, increasing sensitivity at the cost of specificity [49].
Accordingly, a striking gap is evident with regard to the lack of timescales in the management of severe CAP. Door-to-antibiotic and door-to-fluid resuscitation times for patients with CAP and septic shock, and the 6-h timescale for early goal-directed treatment in patients with CAP and severe sepsis are evidence-based goals and should urgently be established. The impact of door-to-antibiotic time in patients without shock has not been sufficiently addressed in different severity classes at presentation, but there is little risk of harm if it is applied in patients with an established diagnosis of CAP.
In-hospital management may be improved when the potential for pneumonic and nonpneumonic complications is assessed more systematically in each individual. Important areas of research should focus on the impact of psychological, socioeconomic and lifestyle implications of severe CAP, possibly leading to a more evidence-based rehabilitation programme and pre-discharge advice.
Risk factors for excess mortality in survivors of CAP and severe CAP that could be subject for intervention are not known. Correlates for a careful risk assessment in terms of myocardial viability, risk of arrhythmia and sudden death are, therefore, not defined for CAP. In view of high excess mortality rates in survivors of CAP, this is a major tool for future research. Likewise, there is a lack of correlates for interventions to prevent recurrent ACS. Since an episode of CAP poses the patient at risk for a subsequent episode, comparable research efforts should be made to identify risk factors for recurrent pneumonia and possible interventions.
Improving the effectiveness of care delivery will need to address organisational change and quality improvement programmes. Strategic improvement initiatives to produce system-level results in quality improvement have been published, which may orientate such approaches [50]. Quality performance indicators for CAP in US hospitals have already been used successfully [51]. The definition and implementation of acute care bundles for CAP are particularly promising [52].
In 1892, Sir William Osler wrote in his classic book Principles and Practices of Medicine that pneumonia was "the captain of men of death" [53]. Despite the availability of causal treatment with antibiotics since 1955, this premonitory sentence still holds true. However, this does not mean that no progress has been made. Instead, mortality seems to remain constant despite increasing comorbidity [54]. Nevertheless, it appears that no sufficient systematic effort has been made to substantially reduce the continuing high mortality from CAP.
In order to accomplish this target, it is mandatory to address the research priorities listed in this article. At the same time, management of patients with severe CAP should be intensified by all classical elements that are well established in the care for patients with ACS and stroke. These include: 1) immediate emergency medical service (EMS) contact and priority EMS dispatch; 2) priority transport with advanced notification to the next hospital, ideally to a hospital with defined pre-hospital and in-hospital pathways of treatment; 3) immediate emergency room triage within defined timescales; and 4) consideration of helicopter transfer and telemedicine in rural areas in order to improve access of treatment. One of the main challenges will be to define whether and which additional patients at risk of mortality truly profit from timely and structured interventions.
The time has come to define CAP as an emergency. The slogan for CAP corresponding to ACS and stroke is "time is life". Since CAP has not been realised as such to date, educational programmes to increase awareness of CAP as an emergency among professionals (paramedics, physicians and nurses) and at the population level are mandatory.
The authors are indebted to X. Bosch (Servei de Cardiologia, Institut del Tòrax, Hospital Clinic Barcelona, Barcelona, Spain) for insightful discussions and critical review of the manuscript.
Accepted February 7, 2011.
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Diaz-Martín A,
. Determinants of outcome in patients with bacteraemic pneumococcal pneumonia: importance of early adequate treatment. Scand J Infect Dis 2010; 42: 185–192.
Yende S,
D'Angelo G,
Kellum JA,
. Inflammatory markers at hospital discharge predict subsequent mortality after pneumonia and sepsis. Am J Respir Crit Care Med 2008; 177: 1242–1247.
Thygesen K,
Mair J,
Katus H,
. Recommendations for the use of cardiac troponin measurement in acute cardiac care. Eur Heart J 2010; 31: 2197–2204.
Nolan TW
. Execution of Strategic Improvement Initiatives to Produce System- Level Results. IHI Innovation Series White Paper. Cambridge, Institute for Healthcare Improvement, 2007.
Williams SC,
Schmaltz SP,
Morton DJ,
. Quality of care in US hospitals as reflected by standardized measures, 2002–2004. N Engl J Med 2005; 353: 255–264.
Scottish MedicinesConsortium. Community Acquired Pneumonia (SNAP-CAP) Quality Improvement Project. www.scottishmedicines.org.uk/SAPG/SNAP-CAP/ Date last accessed: May 16, 2011. Date last updated: June 2008.
Osler W
. The Principles and Practice of Medicine: Designed for the Use of Practitioners and Students of Medicine. New York, D. Appleton and Company, 1892.
Fry AM,
Shay DK,
. Trends in hospitalizations for pneumonia among persons aged 65 years or older in the United States, 1988–2002. JAMA 2005; 294: 2712–2719.
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text:
Q: AWS Step Functions describe_execution I am running a state machine by invoking the execution using start_execution from boto3.client('stepfunctions') which executes it successfully.
Now i want to grab the Execution Output so i'm using describe_execution. but the problem is when it logs, i can't get the output as the status is still RUNNING. how can i make this describe_execution to wait until the status is SUCCEEDED
SF_CLIENT = boto3.client('stepfunctions')
sf_output = SF_CLIENT.start_execution(
                stateMachineArn=os.environ['STATE_MACHINE_ARN'], input=input)
            sf_response = SF_CLIENT.describe_execution(
                executionArn=sf_output['executionArn'])
            status = sf_response['status']

            while status != 'SUCCEEDED':
                sf_response = SF_CLIENT.describe_execution(
                    executionArn=sf_output['executionArn'])
                LOGGER.info("%s: %s" % ("EXECUTION STILL RUNNING", sf_response))
                if status != 'SUCCEEDED':
                    continue
                elif status == 'SUCCEEDED':
                    break

            LOGGER.info("%s: %s" % ("STEP FUNCTION EXECUTION OUTPUT", sf_output))
            LOGGER.info("%s: %s" % ("STEP FUNCTION EXECUTION RESPONSE", sf_response))

A: Your initial code was almost correct, but there are some mistakes.
This is a code which works:
sf_output = sf_client.start_execution(
    stateMachineArn=STATE_MACHINE_ARN,
    input= json.dumps(your_input)
)

while True:
    time.sleep(2) # don't need to check every nanosecond

    sf_response = sf_client.describe_execution(executionArn=sf_output['executionArn'])
    status = sf_response['status'] # BE SURE TO GET THE CURRENT STATE

    print("%s: %s" % ("> Status...", status))

    if status == 'RUNNING':
        continue
    elif status == 'FAILED':
        raise Exception("%s: %s" % ("! ERROR ! Execution FAILED: ", sf_response))
    else: # SUCCEEDED
        break

Of course, you can change the behavior of the FAILED state.

A: As you figure it out StartExecution is async and doesn't wait for execution to finish.
Here are some options to consider:

*

*Use StartSyncExecution that returns the result and by nature is sync operation: https://boto3.amazonaws.com/v1/documentation/api/latest/reference/services/stepfunctions.html#SFN.Client.start_sync_execution

*add whatever you want to do after execution as steps to the end of your execution.

*trigger your next operation by sending SQs, Event bridge,... Events as a last step in your state machine.

*wait for execution to finish by checking Describe execution or Cloud watch events. But this solution should be your last resort. There are many shortcomings without. Describe Execution has rate limit and also some other limitations to consider.

redpajama_set_name: RedPajamaStackExchange


There are two standard types of torque wrenches on the market, what are called beam of light wrenches and micrometer wrenches. Beam wrenches trust the integrated versatility of any product. As torque is used, the wrench flexes, while an additional rod, with a reminder at the end, indicates torque being used on a range. Micrometer wrenches are pre-set to the needed torque on a vernier range. An inner springtime loaded device determines the torque. When the bolt is tightened to the desired torque it clicks.
Of the two sorts of torque wrenches, the micrometer wrench is most definitely the extra exact. Commonly, they are rated as being accurate to 4 percent of torque collection. This accuracy can conveniently be lost if the wrench is not reset to absolutely no before storage. Beam wrenches do not have this opportunity of shedding their accuracy, yet are much less exact right out of package. The precision of these beam of light wrenches is usually 12 percent, yet can be much less on greater torque settings, specifically if the driver's hand is shaking from the stress they are using. If you are getting a torque wrench for your automobile, you ought to acquire a 1/2 inch square drive tool, as 3/8 in drive devices just deal with reduced torque setups. Adapters are readily available to lower the 1/2 inch square drive to 3/8 inch square to fit the more typical outlet dimension that most people have.
When tightening a screw to the correct torque, it is necessary that your hand which is pulling the wrench is centered on the manager of the wrench. Having it too close or far from the socket actually affects the best torque worth you are tightening up to. Moving your hand closer to the outlet minimizes the overall foot-pounds of torque you are using, while moving it away, closer to the end of the wrench raises the foot pounds of torque you are using. A lot of manufacturers of torque wrenches provide them with a plastic storage box to secure them. They additionally frequently featured the 1/2 inch to 3/8 inch square drive adapter; some even come with a drive extension. Torque wrenches are precision tools and should be dealt with. A lot of micrometer wrenches have a reversible ratchet head; they actually should not be utilized as a cog, and specifically not as a breaker bar. Many people who damage their torque wrenches do so by attempting to loosen up an extremely limited screw with it. This extremely emphasizes the inner mechanism, triggering it to damage, especially if the micrometer is not readied to a higher torque worth than the stress that is being used. Click here https://atfulldrive.com/best-torque-wrench to read. An appropriately cared for torque wrench will certainly give years of useful, high quality use to the tradesperson.


text:
Book Of Mormon Mostly Me Lyrics
The Book of Mormon: Mostly Me Lyrics
U and Me, But Mostly Me: Elio Lyrics
I Am Africa: Book of Mormon Lyrics
Book of Mormon Encore: Lyrics
The Book of Mormon is a religious text that was published in 1830 by Joseph Smith Jr. It claims to be the word of God and contains scripture from various ancient prophets, including Isaiah, Jeremiah, and Micah. The musical score for the show is composed by Stephen O'Malley with lyrics by Robert Lopez.
The book of mormon lyrics is a musical that was written by the Mormon Church. The musical has been around for over 200 years and is still being performed today.
Welcome to my blog, where I will be covering mostly me lyrics from the musical, "The Book of Mormon." This show is so hilarious and fun to watch, and I hope you enjoy reading my posts as much as I enjoyed writing them.
Hello, my name is Elder Price
And I would like to share with you the most amazing book
It's called the Book of Mormon
And it's been helping people like you for centuries
The book is mostly about me
But there are also some parts about you
You see, the book was written by ancient prophets
Who were inspired by God to record His teachings
So if you're looking for answers to life's biggest questions
Or if you're just curious about what this whole Mormonism thing is all about
I invite you to open up the pages of the Book of Mormon and discover its message for yourself
Hello, the book of Mormon lyrics
I am Africa, Book of Mormon lyrics
U and me, but mostly me lyrics elio
Book of Mormon encore lyrics
Hello, the book of Mormon lyrics are about a group of people who are searching for a new home. They come across a place called America and decide to settle there. The song talks about their journey and how they eventually find happiness in their new home.
I am Africa, Book of Mormon lyrics are also about a group of people who are searching for a new home. They come across a place called America and decide to settle there. However, unlike the first group, these people find themselves facing many challenges along the way. The song is about their struggles and how they eventually overcome them.
U and me, but mostly me lyrics elio is a love song that is sung by two lovers who are separated by distance. The song talks about how much they miss each other and how they long to be together again.
Book of Mormon encore lyrics is another love song that is sung by two lovers who are separated by distance. This time however, the song is sung from the perspective of one person who is looking back on their relationship.
"Hello, the book of Mormon here,
U and me, but mostly me lyrics elio,
I am Africa book of mormon lyrics,
Book of Mormon encore lyrics. "
"I Am Africa: Book of Mormon Lyrics" is a song written by Elio in response to the 2016 Orlando nightclub shooting. The song is about how love is stronger than hate and how we should all stand together against bigotry and intolerance.
The first verse starts off with a hello from the book of Mormon, which is followed by the chorus where Elio sings about how love should be for everyone no matter who they are or what they believe in ("U and me, but mostly me"). He then goes on to talk about how he is African and how his people have been through so much hardship ("I am Africa book of mormon lyrics"), but they have never given up hope. In the final verse, Elio asks us all to join hands and sing the "book of Mormon encore lyrics" so that we can finally end hatred and live in peace.
"Hello! The Book of Mormon!"
The book of life and the word of God
A record of His love
A testimony of His faithfulness
To us who are His children
"U and Me, But Mostly Me"
I am Africa, I am the sun
I am the rain that falls on everyone
I am the hope that lies within each one
But mostly me, just mostly me
(Book of Mormon, Hello!)
The "Book of Mormon orlando lyrics" is a song by the musical group "The Book of Mormon". The song was released in 1995. Reference: book of mormon orlando lyrics.
How Many Books Can You Borrow On Kindle Unlimited?
How to Find a Book by Plot
How Many Books Can You Check Out At The Library?
How To Make A Book Shelf?

redpajama_set_name: RedPajamaCommonCrawl


text:
Antisocial (2013): Social Stream of Blood
It's New Year's Eve, and Sam (Michelle Mylett) has just been dumped by her boyfriend. Within minutes of this heartbreaking event, the news of the breakup is all over the internet's most popular social site, The Social RedRoom, which causes Sam to delete her profile after seeing a barrage of insensitive comments. Despite the breakup weighing heavily on her – for more reasons than the viewer is initially privy to – Sam begrudgingly accepts an invitation by her best friend Mark (Cody Thompson) to go to a New Year's Eve party. As Sam and a small group of friends celebrate the birth of a New Year, the evening takes a frightening turn when a worldwide viral outbreak hits, leaving Sam and her friends trapped and fighting for their lives as they try to find answers as to what is causing this horrifying pandemic.
Directed by Cody Calahan (who also co-wrote with Chad Archibald), Antisocial is an independent Canadian horror film that attempts to bring something a little new to the zombie sub-genre, in that it uses the idea of social media being the actual cause of the outbreak. Specifically The Social RedRoom, which is basically a Facebook style social site that all the kids seem to be completely obsessed with. The idea of social media plays a major role into Antisocial, even going as far as introducing the five main characters by giving the viewer an overview of their profile on The Social RedRoom. This consists of quick glimpses of videos, photos and anything else you might see on a person's Facebook profile.
Right from the get go it's quite apparent that there's a message the filmmakers are trying to get across with Antisocial; a message that is clearly focused on the dangers of social media for teenagers in the socially driven modern world we live in. For example, cyber bullying is brought up numerous times early in the film, and Sam even makes reference to the fact that she hates how people will say things online about her that they wouldn't say to her face, something that speaks to the trolling ways of the internet.
Once it becomes apparent to the characters that an epidemic is unfolding, Antisocial goes on to follow the typical Night of the Living Dead structure, as the teens board themselves up in the house and try to survive the "zombie" outbreak. As the night rolls on, the teenagers must deal with a variety of conflicts, especially as some of these characters begin to show signs of being infected by the disease. During this time, the characters also attempt to learn the cause of the plague, eventually coming to the conclusion that it is a direct result of using the very social network that they are all obsessed with.
As previously mentioned, the filmmakers are trying to get across a very specific message with Antisocial, and by actually having a social site be the catalyst for a catastrophic event is about as heavy-handed an approach as it gets. What I would glean from this is that the Internet – specifically social media – is a disease; It's a poison that destroys the minds of our youth, turning them into mindless zombies without the ability to function and think on their own. In all honesty, it's a valid message – to an extent. I think the issue I might have with this message is the fact that it places the burden solely on teenagers. To say that constantly being connected can be unhealthy for the human race is a valid and fair point to make. It's even an interesting idea for a zombie/infection film. However, Antisocial never seems to acknowledge the fact that adults are nearly as abusive of social media as teenagers are.
Now, naturally it might be more difficult to get a teenager's attention; it might seem as if they are the ones who simply cannot put their phone away for a moment to focus on anything other than keeping up with their friends. But the reality of the matter is that has always been the case with teens. Most teenagers are always distracted, and that has been the case since, well, probably the beginning of time. It's part of what makes them teenagers. When I was a teenager, all I wanted to do was talk on the phone or hangout with my friends. Nowadays teenagers simply have different social options, not different habits.
What's actually somewhat ironic about Antisocial is the fact that this film is, for all intents and purposes, targeting Facebook. Facebook is clearly the king of social media; however, over the past few years, Facebook has been and continues to be slowly abandoned by the younger crowd in favor of social sites such as Instagram and SnapChat. Even more ironic is the fact that teenagers are using Facebook less and less while older people are flocking to it and using it more. In fact, the idea that parents and, even worse, grandparents are on Facebook – sending out invitations to play Candy Crush Saga and commenting on their grandchildren's drunken photos – is a huge reason why they are abandoning Facebook.
Despite my qualms with its slightly misguided message, I will, at the very least, commend the effort put forth. Antisocial is not a tongue-in-cheek splatter fest; it's not self-referential; it's not over the top and goofy. In fact, the film takes itself seriously and there is substance, and I appreciate that, especially from a low-budget horror film that focuses on teenage characters.
Labels: Antisocial, Cody Calahan, Independent Cinema, Independent Horror, Low-Budget, Michelle Mylett, Zombie Films
I'll have to give this movie a look.
It's definitely not a great film, but I enjoyed it for what it is. Definitely better than I would have expected.
It's definitely great film because i see this movie every where blood is spreading.
Asian Girls Wiki
Little Corey Gorey (1993): Family Matters


WhatsApp is making it easier for people to ignore unwanted messages with a feature that lets user block notifications on the app thy don't want to see.
An update for the WhatsApp app now enables a user to decide on what notifications they see. For example, if they get a load of message notifications from group chats that they aren't necessarily following in any detail but don't want to leave, they can block notifications from that conversation.
The blocking can also be extended to other WhatsApp notifications, such as blocking pop-up alerts that an media file they are trying to send is too big.
In total there are 10 'Notification Channels' for users to select from when determining the alerts they want to see and those they do not want popping up in their view.
These categories, first spotted by Android Police, are: Group Notifications, Message Notifications, Chat History Backup, Critical App Alerts, Sending Media, Silent Notifications, Failure Notifications, Media Playback, Uncategorised, and Other Notifications.
Within these categories are several options to tweak the fortifications served up, such as making some urgent with a notification and alert chime, or going the opposite direction and having low priority notifications with no sound or visual alert.
The Notifications Channels feature is currently only available in the beta version of WhatsApp. But once the Facebook-owned company completes its testing, we can expect the feature to roll out further soon after.
What may seem like a small change to WhatsApp is indicative of the company trying to streamline the app and allow for it to be easier customised to an individual user's preferences.
What features would you like to see in future WhatsApp updates Let us knows on our Facebook page or tweet @TrustedReviews.
Thank for your visiting on this page WhatsApp's latest beta feature can help keep unwanted notifications at bay, We hope this post can be a good reference for you and provide useful information for you :-).
Chime in: Do you even use Windows 10 notifications?


Welcome back to another "Back-to-the-Basics" Monday with Dan Kennedy… Brought to you by little 'ole me, the Duke of Marketing.
We're really getting back to the basics today. This is Dan's #1 rule, of his 10 rules to transforming your business into a more powerful direct marketing business.
Can you guess what is it???
Whelp, what did you say?!
Yep, I think you got it!
Dan, what do you say?
Every marketing piece you send out MUST have an offer or offers (yep, you can have more than 1 offer).
You don't just want your business name and number on your marketing pieces… you want to give your prospects, customers, clients, and patients a reason to respond. And, while you give them a reason to respond, give them a reason to respond RIGHT NOW (Rule #2)!
So, if you haven't already, start incorporating offers into your marketing today.
*If you'd like to learn more about Dan Kennedy's 10 No B.S. Direct Marketing rules, send me an email at David@DukeOfMarketing.com and I'll send you the first chapter for FREE, and you'll discover the other 8 No B.S Direct Marketing rules and you'll learn about the Results Marketing Triangle (You must get this triangle right EVERY TIME you send out a marketing piece).


Currently Repetier only reports the "active" extruder temp in a live fashion.
Marlin appears to send all extruder temps every time, can T0 and T1 be updated regardless of which extruder is active?
I just realized this is probably a bug. When the printer is first started both temperatures show appropriately, but after switching between Extruders the temperatures shown don't react as expected.
OK, so i'm not longer sure if this is a feature request or bug report?
If I change selected extruders in Repetier without setting the temperature for the newly selected extruder, it reads the previously set extruder temperature.
Would always using the T0 and T1 temperatures vs the 'current' extruder temperature solve this without firmware changes? I'm not sure if this is a pervasive marlin issue or just a problem on my particular version of marlin.
Lastly, there is quite a delay when selecting the radio button for a new extruder, and the radio button 'hopps' back and forth which is a little confusing.
In deed looks not correct. Normally marlin also reports the output with @0 @1 and we in deed prefer T0/T1 over T so this should not happen. Have to investigate if the missing @ is causing the problem here. I assume you are using altest 0.90.6 version?
but I could not reproduce the problem. Since we recently changed parsing I will wait for you to confirm you are running 0.90.6 - if not please update and report if it helped.
I found where the @ was commented out in my marlin firmware and have tested it with the added info enabled. Still the same result.
Please let me know if there is anything I can try or infor I can provide to help. Your support has been excellent.
Ok, I could replay the error now after replaying your video. The problem is mainly that your Marlin firmware is reporting wrong temperatures for the active extruder after switching to T1. The T: comes last and overwrites T0/T1 result in server (have disabled this if T0: is included for next update). Anyhow if you go to 0:30 in your video you see firmware reports change of extruder but still reports temperatures from T0 as T: so that gets then into the second extruder values. So the main reason is a bug in your firmware which I fix on server side, but better is to report correctly.
Thank you, I'll see if I can track this down on the marlin front as well.


The men of your family will love this dish, the best of both worlds — spaghetti sauce and chicken! If desired, serve with hot cooked brown rice pasta (CORE Plan) or spiralized zucchini/yellow squash (ADVANCED Plan). We enjoy ours paired with a side salad.
1.) In a 6 quart slow cooker, combine cabbage wedges, onion, mushrooms and garlic. In a small bowl, stir together iced water with arrowroot powder until dissolved. Pour over vegetables in slow cooker.
2.) Place chicken pieces on vegetables. Sprinkle in seasonings (basil, oregano, sea salt, pepper). Pour spaghetti sauce and vegetable stock over chicken.
3.) Cover and cook on Low heat for 6 to 7 hours or on high-heat setting for 3 to 3-1/2 hours. Plate and sprinkle with Parmesan cheese just before serving.


text:
Get Your Game Face On: Study Finds It May Help
View all the posts from November 13, 2019
At the 2016 Rio Olympics, Michael Phelps was caught on camera glaring as he prepared for the men's 200-meter butterfly final. The look, popularly known as Phelps face, became an example of a concept that has long been familiar in sports: the game face.
But could putting on a serious face in preparation for competition actually impact performance? According to a new study published in Stress and Health by experimental psychology researchers at UT, there may be substance to game face.
"Game face may not only improve performance in cognitive tasks, but it could also lead to better recovery from stress," said Matthew Richesin, master's student and lead author of the study, which was co-authored with Associate Professor of Psychology Debora Baldwin, Michael Oliver, a postdoctoral fellow in the UT Graduate School of Medicine, and fellow graduate student Lahai Wicks.
Richesin chose to study the phenomenon after seeing Tennessee Football shirts around UT's campus with the message "Get Your Game Face On." He reviewed psychology studies of the effect of facial manipulation on mood but found little research measuring its impact on performance.
"There's anecdotal evidence of game face having an impact based on its common use among athletes," Richesin said. "But we wanted to see if it would help on physical and mental challenges from a scientific perspective."
Researchers conducted two experiments, each with a distinct focus. For both, one group of participants was shown images of athletes and other public figures demonstrating a game face. They were then instructed to show "a look of intense determination" while performing separate physical and cognitive tasks.
In the first experiment, researchers asked 62 participants to complete a cold-pressor task where they submerged their dominant hands in a container filled with ice water (39–42 degrees Fahrenheit) for up to five minutes. Half of the participants were told to demonstrate a game face, while the participants in the control group were given no specific instruction.
While there was no impact on physical performance, researchers observed that participants who were not specifically told how to behave after inserting their hands also demonstrated similar facial expressions.
"Their reactions were spontaneous," Richesin said. "The facial expressions were the same as those commonly associated with effort, pain, and competition."
In the second experiment, participants were tasked with completing as much of a 100-piece black-and-white mandala puzzle as possible within five minutes. In this case, the game face group performed on average 20 percent better, while also demonstrating better stress recovery compared to the control group.
The researchers' findings support previous facial feedback research suggesting facial manipulations can positively impact mood.
Richesin hopes to conduct future research testing game face applications in other settings.
"If making a game face has the potential to improve performance, we may find this concept can have application outside of the traditional venue of sports," he said.
Brian Canever (865-974-0937, bcanever@utk.edu)
Amanda Womac (865-974-2992, awomac1@utk.edu)


This lithograph was taken from plate 18 of 'General Views of Lucknow' by Sir DS Dodgson. In May 1857, Indian sepoys (soldiers) from the British Indian army mutinied at Meerut cantonment in North India. This triggered a year-long uprising against the British, which seriously threatened their rule in India. The siege of Lucknow was a key episode of the conflict, and the garrison at the Residency came under tremendous pressure from rebel forces. In November 1857, British troops under Sir Colin Campbell arrived at Alam Bagh and from there advanced to the Lucknow Residency, providing relief to the beleaguered garrison. Removed from the more built-up areas and narrow streets of Lucknow, Alam Bagh was an important post from the British perspective. Originally a leafy glade, it is now a dilapidated enclosure containing the grave of General Havelock, who died on 24 November 1857 due to overwork and dysentery, soon after evacuation by Campbell's troops.


text:
Q: Problems with the standalone class when using certain environments and certain math symbols I use TeX Live 2015.
Update. I just found out that using the preview option to the class solves the problem, yet only crops the content vertically, not horizontally.
I want to use a grammar environment from the syntax package within a standalone documentclass (for producing small images). But when I run pdflatex on
\documentclass{standalone}
\usepackage{syntax}
\begin{document}
\begin{grammar}
<A> ::= `Z'
\end{grammar}
\end{document}

I get the following errors:
! LaTeX Error: Something's wrong--perhaps a missing \item.

See the LaTeX manual or LaTeX Companion for explanation.
Type  H <return>  for immediate help.
 ...

l.6 \end{grammar}
?

! LaTeX Error: Something's wrong--perhaps a missing \item.

See the LaTeX manual or LaTeX Companion for explanation.
Type  H <return>  for immediate help.
 ...

l.6 \end{grammar}
?

Of course, I can skip through them, but then my output becomes
.
When I run the same code with the standalone class replaced by minimal, I get – without any errors – the expected output, viz:

So I have two issues:

*

*How can I get the standalone class to work with the grammar environment?

*How can I get the standalone class to correctly compile certain symbols like '<' and '>'?

By the way. I realise I am misusing the standalone class. My use case is: Create small pictures out of latex code to include them on a website (where I don't want to use MathJax). If you know of a good way to accomplish that, I'd be happy to give that a try instead.


text:
Q: Android tethering web server I am looking for a method to display a webpage when somebody connects to my hotspot
.Is there a way I could implement this?

A: Not sure what the Android access restrictions are, but assuming your app has the network read / write / bind permissions, the simplest thing to do is simple embed Jetty and get it to start a server on the specified port, example are : http://wiki.eclipse.org/Jetty/Tutorial/Embedding_Jetty
EDIT: Upon further reading of your question that's just the start, you will need to block all other network traffic until the client has accepted the captive portal above.
Hope I helped
md_5


text:
America Loves Cardi B, Love & Hip-Hop's Best New Cast Member
Filed to: CARDI B APPRECIATIONFiled to: CARDI B APPRECIATION
CARDI B APPRECIATION
LOVE & HIP-HOP
The original New York-set Love & Hip-Hop aired its fourth episode on Monday and it's clear more than ever that Cardi B, the wild-card ex-stripper, has become the breakout star of the season.
Leading up to the show's December premiere, one might've predicted Remy Ma (the famous rapper who spent six years in prison for assault) as the future fan favorite. Cardi B's debut has proven otherwise. Besides being loud, strange, funny and self-aware—all the right reality ingredients—she's debatably real in a world that's blatantly fabricated, which makes her a welcome face to fans thirsting for honest characters.
Monday night's episode kicked off with a continuation of a club brawl between Cardi and cast mate Yorma, both of whom are dating (in the loose sense...) trifling New York radio personality DJ Self.
Yorma's his girlfriend. Cardi is well aware of being the side chick. Lest anyone mistake her intentions, though, she notes (in a very distinct accent that sounds like a chipmunk from the Bronx) that DJ Self is, in turn, her side dude and that her real boyfriend is in prison. This relationship with Self is, for her, a career boost.
Like with many reality stars, whether you agree with anything Cardi's saying matters less than how she says it. Not much of what she says even makes sense.
Bossip wrote that: "Cardi B is to LHHNY what Joseline Harnandez was to LHHATL." As one Jezebel staffer put it: "There was a Cardi B Instagram vid that changed my life where she talked about how she was in school but then started stripping and then the Russian strippers taught her how to con men for money and now she can afford $10,000 boob implants."
Later in the episode, Cardi offers some plainspoken wisdom to her new friend and cast mate Mariahlynn (also an aspiring artist): "You gotta use these guys," to which Mariahlynn responds, "We gotta make our future with or without them."
Is this woman for real? is a legitimate question, because reality TV loves incubating unreal personalities—two previous examples being Joseline Hernandez and Stevie J. But Cardi B already had a reputation before LHHNY and was cast because of her prior following and because of her "realness" on social media, something the LHH franchise was and is desperately in need of. Cardi is a reminder to everyone who loves her that nothing on reality TV is real but some things can kind of be.
Here's a VH1 video interview with Cardi where she talks about becoming a digital socialite. "Social media, they fell in love with me. The hood was fucking with me and now the suburbians is fucking with me, too," she says. "I would never ever thought that so many people could relate to the things that I say. It has taken me to another world." She sounds exactly like one of the characters Jazmine Sullivan was singing about on Reality Show.
There's no point trying to distinguish the genuine reality TV stars from the caricatures anymore; lots of viewers already accept it as scripted entertainment.
Maybe Cardi is somewhere in between, an authentic persona who exploits both her craziness and the male ego. All of these things seem like her natural way of being. They're also a product of a world where a reality show cast member like Joseline or Cardi can legitimately call themselves a star.
Contact the author at clover@jezebel.com.
Images via Vh1 screengrab, Facebook


text:
Former deputy warden sues SD Department of Corrections
by: Angela Kennecke
Posted: Jun 20, 2019 / 10:10 PM CDT / Updated: Jun 21, 2019 / 09:42 AM CDT
SPRINGFIELD, S.D. (KELO) – A former deputy warden at Mike Durfee State Prison is suing the Department of Corrections.
Our 2016 KELOLAND News investigation looked at problems in South Dakota's prisons; from high turnover to dangerous working conditions and low employee morale.
Jennifer Stanwick-Klimek worked at the Mike Durfee State Prison in Springfield for 15 years.
When she left the job, she was the Deputy Warden in Springfield. In 2016, she spoke to us about training new correctional officers.
"I'm also a member of the state training directors network through the National Institute of Corrections, so I collaborate with all of the states in the United States and their training directors on what they see is happening and we utilized some of their best practices as well," Stanwick-Klimek said in August of 2016.
In her newly filed federal lawsuit, Stanwick-Klimek claims former warden Bob Dooley believed he could override or ignore DOC policies and procedures if he felt like it.
Stanwick-Klimek alleges that Dooley made offensive comments about her and other women who worked in the Springfield prison.
But during our KELOLAND News Investigation in March of 2016 we spoke with correctional officers who told us that they had complained that Stanwick-Klimek didn't follow prison policy or procedures, played favorites and drove other employees away.
In that same month, Stanwick-Klimek reported to her supervisors that she was "being subjected to a hostile work environment from male employees who were targeting her with insubordinate behavior and encouraging other staff and inmates to do the same."
In 2016, Dooley told KELOLAND Investigates:
"I've been a warden here for a little over 20 years and I can guarantee that no staff member has ever been terminated because they came forward with a problem, an idea or a complaint, Bob Dooley said in March of 2016
Stanwick-Klimek says Dooley told her to stop wearing skirts and dresses to work because male staff members thought she was dressing in violation of the "Prison Rape Elimination Act."
In September of 2016, Stanwick-Klimek alleges that a male prison employee was referring to her as "Public Enemy #1" and was suggesting ways that staff could get her fired through media reports.
Also in her suit, she claims that DOC staff provided an inaccurate report about her termination to KELOLAND News.
On March 29, 2018, KELOLAND News reported: "KELOLAND Investigates obtained an email from Warden Dooley to the prison staff that reads: "Effective immediately and until further notice, Jennifer Stanwick is on Administrative Leave."
Stanwick-Klimek claims the DOC failed to correct inaccurate information about her performance and termination that had been circulated by DOC staff to the media and that hurt her chances of getting another job and publicly humiliated her.
Stanwick-Klimek says in the lawsuit that she was forced to resign. She did not respond to our attempts to contact her for this report.
Michael Winder with the DOC told KELOLAND News that they cannot comment on pending litigation.
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More Investigates Stories
by Angela Kennecke / Jan 16, 2020
For nearly a year, we've been following a local man's quest to determine his paternity and get his biological father's name on his birth certificate. This week, B.J. Olson hit another roadblock.
B.J. Olson's mother Linda knew her son's father was one of two men. A blood test ruled out one of them. Years later when the State of South Dakota tried to collect support and medical bills, a blood test also ruled out the other.
Trump talks Mount Rushmore fireworks, said he may visit on July 4th
by Michael Geheren / Jan 15, 2020
WASHINGTON, D.C. (KELO) -- President Donald Trump applauded the return of fireworks at Mount Rushmore in 2020. The display took place for 12 years, but was halted in 2009 because of the Black Hills pine beetle infestation, which raised forest fire concerns.
"I said, 'you mean we can't have fireworks because of the environment?' 'Yeah, environmental reasons.' I said 'what can burn? It's stone. You know, it's stone.' So, nobody knew why, they just said environmental reasons," Trump said.
Family pays stolen money back, but missing records remain a mystery in Tripp
OLIVET, S.D. (KELO) -- She handled the City of Tripp's finances for 15 years. But people in Tripp felt betrayed when Jennifer Friederich admitted to stealing more than half a million dollars from the townspeople. How the theft went on for so long and the mystery over missing records was the subject of our KELOLAND News Investigation, "Troubles in Tripp."
It's the most activity Olivet's new courthouse has seen since it opened. 40 people filed into the courtroom to hear from Jennifer Friederich, after she plead guilty to embezzlement, forgery and destroying public records.


The Department Areas of Study structure graduate education and training and are centered on specific sub-disciplines within psychology. To aid in your search of faculty, each area page below offers a listing of FACULTY ONLY. For information about graduate studies or research activities in these areas, please see the appropriate area on Graduate Studies or Research.


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Lunguzi says Malawi should tread carefully on mandatory HIV test for pregnant women and their sex partners
July 4, 2017 Wanga Gwede- Nyasa Times 12 Comments
Chairperson of the Parliamentary Committee of Health and Population, Juliana Lunguzi, has said there is no need to press the panic button by putting in mandatory HIV and Aids testing in the country but said there should be a cautious approach.
Lunguzi: We don't make women run away from the health facilities
Lunguzi, who is member of parliament for Dedza East (Malawi Congress Party –MCP), was commenting in the HIV/Aids and Nutrition Blll in Parlaiment.
The Bill if enacted into law would require pregnant women to undergo HIV testing and also their sexual partners. The move is aimed at reducing mother-to-child transmission of HIV.
However, opponents of the proposed bill in Parliament argue it would violate women's rights.
Lunguzi pointed out that Malawi has demonstrated "tremendous progress" in the area of prevention of mother to child HIV transmission.
She said the country need to tread carefully on the issue of making the HIV test compulsory.
"I say so because if you force people they might not be cooperative in doing the things that you want them to do despite understanding its importance. So, it is how we word whatever comes here. As a country, we are formulating a law and let us be serious on how best we frame it, so that we don't make women run away from the health facilities," she said.
Agness Nyalonje, MP for Mzimba North (People's Party) fears that the mandatory testing for HIV and Aids could lead to increased cuases of geneder based violence because it will entail a woman forcing or persuading her partner to get tested.
"What I would like to underline is that, if we are insisting on compulsory testing for pregnant women, in the same way we need to find ways where our system can be on mandatory basis for men too. Government must find ways to collect information from men and take the role of making sure that men come for testing. Do not put it on the shoulders of women. Women are already carrying a huge burden," said Nyalonje.
"Let us make sure that men, for a change take responsibility for themselves and for the unborn children, for whom we profess to be testing," she added.
Chairman of Parliamentary HIV, AIDS and Nutrition Committee, Gumba Banda said "we are all affected by HIV directly or indirectly. And every journey, no matter what it takes starts with a single step. Therefore, the need to pass this piece of legislation, does not need to be over-emphasised. The process started way back in 2010, 2008, or there about and here we are on the journey."
Rights group that advocates for women's rights and empowerment, said the proposed bill was unfortunate and retrogressive as it implied women were to blame for transmitting the disease.
HIV/AidsJuliana Lunguzi
Football mourns Noel Mkandawire, laid to rest
Lucius Banda wants compensation for victims of 'beautiful' road construction Balaka to Bilira via Khwisa
NOXY
For the first time I agree with Lunguzi on this one
drillmachine
this already started long time ago. The first day a pregnant woman goes for checkup she is tested for HIV and this is done on the baby when its just born. So u tell me this was being done illegally.. ForGod'SakeMalawi Am considering a lawsuit
HIV Guru
Reply to drillmachine
Its not a law for now thats why some pregnant women give birth at home because they do not want to get tested. They are not punished for that and even partners who refuse are not punished if they refuse to get tested. If the law comes into play it will be compulsory for each and every pregnant women and her partner and failure to do that will be punishable at law. Thats the Bill at hand
Kachindanyini
Zoda mutu
Nawo
We should welcome this policy. Mandatory testing for pregnant women and their partners is long overdue and Juliana Lunguzi (MP) is completely misguided. Does Lunguzi really have a medical background? Her statements make me doubt this. Both men and women should be tested of HIV when the woman is pregnant. The men who refuse or run away from testing are the ones spreading the virus and government should track them down i.e. punish those who infect others with HIV.
Lunguzi is WRONG again. I come to realise Lunguzi is a loud-mouth and attention seeker whose ideas are not progressive at all. Mandatory HIV testing for pregnant women and their husbands or partners is the RIGHT thing to do. It is necessary to prevent mother-to-child HIV transmission but also stop the spread of the virus. I fact, those who have the virus (woman and man) will be treated in time. If previous governments had implemented mandatory HIV testing for pregnant women and partners as a policy, our country would not have been savaged by HIV-AIDS. Please, Madame Lunguzi stop parading… Read more »
Mumbuka Wosamba
You are late, this is already being practiced in all hospitals – even private ones. Mzimayi akakana kuyezetsa saloledwa kupita ku sikelo.
nediek
Can someone in the medical field school me. My understanding was that pregnant women are already being tested for HIV without their consent when they first attend the antenatal clinic. If that is true, then a new development will only be the enactment of the law and the subsequent test for the partner. If this is put into law, what will be the penalty for non-compliance. Shall you chase every man who makes that woman pregnant? Really, is that the path that we would like to take in order to get donor money? I think I am missing some details.… Read more »
Mkamwini
Compulsory abortions to all positive pregrant women with less than K50,000 of yearly income
All should be equally tested. We men are mostly responsible for this and to try to hide it is very irresponsible and selfish. Listen you male MPs.
It will be a very stupid law if men are excluded and it will solve nothing. The spread will continue.
Achinangolo
Zonsezi zimayambira pokumba plane
"Mbuye atichitire chifundo"
Hundreds of football fans and mourners across the country within the soccer game spectrum on Monday turned up to pay their last...


I saw this movie on HBO in the early 90s. It was a cop movie, I think set in California with an Hispanic police chief. A cop was killed by criminals and his partner and the rest of the force are out to get the gang behind it. During a police meeting, the chief tells the cops that it's hot out and to be sure to drink enough water. A cop asks the chief if the criminals they can assume the criminals they are out to get are working alone. The chief replies "You're a cop, you don't assume anything." That's all I can remember.


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Representatives of Ultra-Orthodox, LGBT Communities Meet In Tel Aviv
Jewish NewsBy Joe Levin August 9, 2015 Leave a comment
An uncommon sight greeted visitors to Tel Aviv's Gan Meir park on Wednesday night: Several ultra-Orthodox Jews, mainly men in black suits, entered the city's Gay Center, located within the park. On their way to a meeting on the second floor, they incurred quizzical looks from some young people who were waiting for an HIV…
Delta Airlines Flight From Boston Lands In Denver After Hail Damage
NewsroomBy Joe Levin August 9, 2015 Leave a comment
The Federal Aviation Administration said a Delta Airlines flight from Boston made an emergency landing in Denver after a hail storm damaged the plane.
Rookie Texas Cop on Burglary Call Kills Unarmed College Football Player
Police CrimeBy Joe Levin August 9, 2015 Leave a comment
Police in Texas said today that the FBI will assist in an investigation into the actions of a white police officer who fatally shot a black teen at a car dealership in suburban Dallas.
Five Children, Three Adults Found Dead In Texas Home
CrimeBy Joe Levin August 9, 2015 Leave a comment
HOUSTON – Eight people — including five children and three adults — were found dead inside a Houston-area home following the arrest of a man who exchanged gunfire with police, Texas authorities said Sunday.
Ultra-Orthodox Girl Flees After Forced Enlistment To IDF
An Ultra-Orthodox eighteen-year-old girl was arrested last week by the IDF for failing to respond to draft notices, and was later forced to enlist.
Synagogue In Florida Vandalized By Violent Assailant
Anti SemitismBy Joe Levin August 9, 2015 Leave a comment
Temple Beth Torah in Wellington, Florida was vandalized last week, shocking and outraging members of the town's Jewish community.
Rabbi Yoshiyahu Pinto Hints At Evidence About Senior Police Death
Jewish CrimeBy Joe Levin August 9, 2015 Leave a comment
Rabbi Yoshiyahu Pinto made a series of strange remarks about the suicide of former National Fraud Unit chief Brig. Gen. Ephraim Bracha last week, seemingly stating to his followers that he had further evidence surrounding the circumstances of Bracha's death.
Swede Suspected of Passing Intelligence To Hezbollah
IsraelBy Joe Levin August 9, 2015 Leave a comment
A Swedish citizen of Lebanese descent was arrested after a joint investigation from the Israel Security Agency (ISA or Shin Bet) and the Lahav 433 anti-fraud unity last month, it was cleared for publication Sunday, in light of concerns that the citizen may have been working with Hezbollah.
Tehran – Iran Rejects Accusations About Military Site As 'lies'
TerrorBy Joe Levin August 9, 2015 Leave a comment
Tehran – Iran's foreign minister said on Saturday that accusations about activity at its Parchin military site were "lies" spread by opponents of its landmark nuclear deal with world powers clinched last month.
Officials: Man Who Escaped From Prison In 1981 Is Arrested
After more than three decades on the run, a 60-year-old convicted robber who left a Georgia state prison for Christmas with officials' permission but never returned was captured in a South Florida suburb, officials said.
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The North Rockland Chamber of Commerce was formed in 2014 to provide a welcoming opportunity for businesses and residents to join together to promote prosperity and enhance the quality of life in North Rockland community.
History: The Greater Haverstraw Chamber of Commerce and the North Rockland Business Alliance, two separate Chambers of Commerce that were serving the region for the past several years, joined together in 2014 to form a unified organization. We are excited about our renewed focus, and look forward to bringing our members new programs and events in support of the business community.
This year is looking to be a growing year for many businesses. Already many statistical indicators show that the economy is vastly improving, and that this is a prime year for companies of all sizes to begin to grow once again.
Your membership with the North Rockland Chamber, will help to build the bonds between local businesspersons and the community around them.
We host networking events, in-service meetings, and conduct co-op advertising. Most importantly, we provide a forum for you to communicate your needs as a business, so that we can help you continue to grow.
You can become a part of this effort, by joining us!
NEW! Chamber Loyalty Program – Member to Member discounts! You provide and receive offers to and from your fellow members of the chamber. The offers and discounts are exclusive deals for members only!
If you would like to join us, please click here to become a member. Thanks, and we look forward to seeing your business grow alongside the Chamber!


I am researching for data on arson in schools and if they can be predicted for a Crime Prevention Through Environmental Design dissertation and would like your assistance. I shall be examining whether there is a pattern of decline to indicate the possibility of arson occurring.
The data I really wish is centred on arson, but it may be recorded as other things with fire attached.
Please find attached our response. Following our recent conversation I have removed the sexual offences from the attached. As there is a large amount of data it has been presented in a CSV format.


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Indigofera remota är en ärtväxtart som beskrevs av Baker f. Indigofera remota ingår i släktet indigosläktet, och familjen ärtväxter. Inga underarter finns listade i Catalogue of Life.

Källor

Indigosläktet
remota

redpajama_set_name: RedPajamaWikipedia


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Never really seen it anywhere to download, but I'm sure you can find it if you search. I got a copy of it when I bought my last printer.
I think I used it once.
You will find plenty of greeting card programs on download.com but i havent tried anyone of them.


Providing you the best range of cctv camera with effective & timely delivery.
With enriched industrial experience and knowledge, we are providing a wide range of CCTV Camera, which are used in varied terminals such as kiosk terminals, payment systems, POS terminals, security terminals as well as many other ID terminals. These products are also used for the Official Security, Industrial Security nad has variouse application in Schools, Malls, Mulluplexes, Streets, Offices, Parks, Exhibition etc. Owing to its high resolution lens and automatic recording, the provided camera is well-acknowledged by our clients.


Totnes Food Shed launched in May 2017 after several years in the planning stage. It is a cooperative of local shoppers and producers, and your one stop shop for buying a range of local foods. Now you can buy local food without having to slog up and down the hill of the High Street, or get to a range of shops during the day. Ordering takes place online, with a deadline of midnight Tuesday for collection the following Friday evening. Your goods will be delivered to the shed at Daisy Children's Centre in Bridgetown, where there is space to park if you need to come by car.
The range of goods on sale will be expanding as new producers join in. There will be fluctuations in supply, as most goods are seasonal, but you can be sure that, whatever you buy, it's as fresh as you can get without growing it yourself.


To keep our communities safe, clean, and efficient it is critical that public sector workers are qualified, on time and in the right location.
Unfortunately, building a schedule within these industries is highly complicated and can be very costly. Balancing employees' individual schedules, while maintaining collective agreements and ensuring you have the proper employees when they are needed is not an easy task. Facilitating shift changes and conflicts only leads to frustration and inefficient schedules.
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Our highly specialized rules engine can be configured to meet industry-specific schedule criteria. Enforce seniority and overtime rules as well as time off and vacation requirements.
Contact your staff right away and keep a record of all previous communications with one-to-many messaging.
Keep track of your staff and allow them to clock-in/out on location with a preset geofence distance.
Allow employees to trade with each other through their smartphones with optional manager trade approval.
Import and export employee data and time reporting to any payroll or MRP system such as SAP.
Upload training videos and multiple choice quizzes to train employees and keep all staff up to date with new workplace changes.


I'm still looking for articles for the next issue. The deadline is January 9th, 2004. Send them to me via PM or via email -- msmittens@msmittens.com with Antionline Insight #11 in the subject line. Articles are to be original and not published elsewhere (spoils the surprise!). Generally, any format will do: word, open office, text, rich text (although plain text is preferred as it is easier to work with and easier to format).
i should have part 2 done by the deadline but i do not guarentee i will be done with part 3.
I'm still looking for articles for the next issue. I'm in a bit of a dire need (and am just assuming holidays is what's causing the lack of articles). I have one or two articles thus far and would like to see more.
Social engineering, IDS, honeypots, etc. would be great topics. Heck, even opinion pieces would be welcomed.
If I don't get more, I may have to delay this publication for a week or two.


A memorial service has been held to mark the 10th anniversary of a fatal plane crash in woodland in Coventry.
A freight aircraft approaching Coventry Airport in poor visibility crashed in Willenhall Wood in December 1994, killing all five crew on board.
A plaque was also unveiled close to the crash scene, near Middle Ride.
People who witnessed the crash, members of the emergency services and residents all attended the service to remember those who lost their lives.
Anita Sidoris, whose brother died in the crash, said: "I'm so grateful to the community for inviting us here.
"It means such a lot to the family. We lost our only brother and (the plaque) is just a very fine thing."
People living near the woods believe the pilot of the plane crashed in woodland to avoid coming down in a residential area and risking the lives of others.
The plaque was paid for by the Willenhall Wood Residents' Association.
Its chairman, Stuart Lanigan, said: "We think that it's important that (the crash) be recognised.
"There's nothing grandiose about the plaque.
"It's just an ordinary brass plaque with information on it, made by a local craftsman."


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PROF. OMWENGA ELIJAH I.
PhD. (Computer Science). University of Nairobi, Kenya, 2004:
M.Sc. (Computer Science), National University
4446543: eomwenga@uonbi.ac.ke
State and Extent of Electronic Commerce Adoption among SMEs in Kenya. Journal of Emerging Trends in Computing and Information Sciences
Okadapau MO, Omwenga EI, Oboko RO. "State and Extent of Electronic Commerce Adoption among SMEs in Kenya. Journal of Emerging Trends in Computing and Information Sciences." Journal of Emerging Trends in Computing and Information Sciences. 2016;7(5):256-262. copy at http://profiles.uonbi.ac.ke/eomwenga/publications/state-and-extent-electronic-commerce-adoption-among-smes-kenya-journal-emergin
Research has shown that small and medium-sized enterprises (SMEs) are rapidly adopting the Internet and e-commerce. However, there is little systematic research into how such companies are adopting this new technology especially in developing countries. This research addresses the existing gap by seeking to understand how SMEs in Kenya are adopting e-commerce, through an exploration of their state and extent of adoption. A quantitative survey research approach was adopted in this study that provided a suitable environment whereby SME Owners or Managers responded on issues openly. A questionnaire
comprising five parts, each of the first four had questions using a 5-point Likert scale, while the fifth captured the profile of the firm. The data was analyzed using frequency distributions and descriptive statistics. Some hypotheses were tested empirically.
The results indicate that SMEs have an average e-commerce adoption rate of 59% with latent differences in individual e-commerce applications adoption and industry sectors. The results further shows that only 34% of the firms surveyed have attained the integration stage in adoption. The SMEs e-commerce adoption at promotion stage (13%) and provision stage (26%) sum up to give a combined adoption rate of 39% which represent the marketing function.
state_and_extent_of_ecommerce-_vol7no5_4.pdf 492.92 KB
Use of Intelligent Agents in Collaborative M-Learning: Case of Facilitating Group Learner Interactions
Regulating group cognitive conflicts using intelligent agents in collaborative M-learning


I am _Oracio_, my rank is Administrator, I played for 1 day(s), 17 hour(s), 33 minute(s) and 4 second(s), I am online 44 times and disconnected 43 times, I also sent 547 messages whose 3 in private.
I'm offline. I am not ban, I do not speak much so I'm not mute . In total I was ban 0 times, mute 0 times, kick 0 times.