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Trends in sepsis mortality over time in randomised sepsis trials: a systematic literature review and meta-analysis of mortality in the control arm, 2002–2016
Robert Luhr1,
Yang Cao2,3,
Bo Söderquist1,4 &
Sara Cajander ORCID: orcid.org/0000-0003-3921-42441,4
Epidemiologic data have shown an increasing incidence and declining mortality rate in sepsis. However, confounding effects due to differences in disease classification might have contributed to these trends.
To assess if a declining mortality over time could be supported by data derived from high-quality prospective studies, we performed a meta-analysis using data from randomised controlled trials (RCTs) on sepsis. The primary aim was to assess whether the mortality in sepsis trials has changed over time. The secondary aim was to investigate how many of the included trials could show efficacy of the studied intervention regarding 28-day mortality.
We searched PubMed for RCTs enrolling patients with severe sepsis and septic shock, published between 2002 and 2016. The included trials were assessed for quality and sorted by date of first inclusion. A meta-analysis was performed to synthesise data from the individual sepsis trials.
Of 418 eligible articles, 44 RCTs on sepsis were included in the analysis, enrolling 13,315 patients in the usual care arm between 1991 and 2013. In this time period, mortality decreased by 0.42% annually (p = 0.04) to give a total decline of 9.24%. In subgroup analyses with adjustments for APACHE II, SAPS II and SOFA scores, the observed time trend was not significant (p = 0.45, 0.23 and 0.98 respectively). Only four of the included trials showed any efficacy with regard to mortality.
Data from RCTs show a declining trend in 28-day mortality in severe sepsis and septic shock patients during the years from 1991 to 2013. However, when controlling for severity at study inclusion, there was no significant change in mortality over time. The number of trials presenting new treatment options was low.
PROSPERO CRD42018091100. Registered 27 August 2018.
Sepsis is a potentially life-threatening condition which is estimated to affect over 30 million people worldwide each year [1]. Recent data suggest that sepsis contributes to between one third and half of all hospital deaths in the USA and accounts for a significant part of the overall costs of healthcare [2,3,4]. The incidence of severe sepsis and septic shock in developed countries has been reported as increasing steadily over recent decades; for example, during 2004–2009, the incidence of severe sepsis increased from 300 to 1031 cases per 100,000 population in the USA [5]. Conversely, several reports from different geographical areas have shown a sequential decrease in sepsis mortality over time. In a large study of European ICU patients over time, the odds of ICU mortality in sepsis patients were lower in 2012 versus 2002 [6]. Similar to this, a study from Germany based on retrospectively collected administrative data for 2007–2013 found a declining mortality trend, although the incidence was increasing [7]. A similar trend was also reported for sepsis patients treated in intensive care units in Australia and New Zealand during 2000–2013 [8], though the authors also identified a substantial variation in mortality risk according to the classification of the diagnosis of sepsis, implying a potential risk that reported temporal trends in sepsis mortality based on administrative data may be biased by misclassification. Results might have been influenced by differences due to increased awareness of the disease or changes in diagnosis coding practices over time, as well as incorrect coding due to retrospectively derived data [9]. Extracting clinical data from electronic databases seems to be the most unbiased way to study trends in hospital mortality [10,11,12,13,14]. With this approach, previous assumptions of declining in-hospital sepsis mortality in the USA were shown to be partly confounded by increased disease awareness and sepsis diagnosis coding [10]. However, the accessibility to large sets of clinical data from electronic health records is often limited in many countries outside the USA and only hospital mortality can be studied.
In order to study trends of mortality in patients with severe sepsis with reduced risk of classification bias, Stevenson et al. assessed the trends of sepsis mortality based on data from randomised controlled trials (RCTs) [15]. They found a decrease in sepsis mortality between 1991 and 2009, consistent with administrative data and supported the use of administrative data to monitor mortality trends in patients with severe sepsis. As this was the first meta-analysis performed with this research question, we wanted to assess if the results were reproducible in a prospectively designed meta-analysis of high-quality sepsis trials, published during a different time interval.
Accordingly, we hypothesised that a trend in the mortality of patients enrolled in the usual care arm of interventional high-quality sepsis studies published between 2002 and 2016 should be concordant with the previously reported trends from RCT data where quality assessments of the included studies had not been performed.
The primary aim of this study was to investigate whether the reported 28-day mortality of patients with severe sepsis and septic shock, included as controls in randomised controlled trials, has declined over time. The secondary aim was to assess how many of the included trials could show any beneficial effect of the studied intervention with regard to 28-day mortality.
According to international guidelines, there is currently no approved sepsis-specific drug or intervention [16]. In addition to investigating any apparent temporal trends in mortality, we therefore also sought to explore how many studied interventions have shown efficacy in terms of mortality.
The study was registered in the International Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/PROSPERO/) and given number CRD42018091100. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) Statement were referred to for methodological guidance [17].
The PubMed database was searched for RCTs of patients with severe sepsis and/or septic shock, published between 2002 and 2016. The full search sequence is detailed in Additional file 2: Table S1.
The research question was devised in accordance with the Patient, Intervention, Comparison and Outcome (PICO) model: P, patients aged 16 years or older presenting with severe sepsis or septic shock; I, all treatments of severe sepsis and septic shock regardless of length of treatment and hospital setting; C, usual care; and O, mortality at 28 ± 2 days.
Two independent investigators (RL and SC) reviewed abstracts in order to select potentially eligible studies according to pre-defined inclusion criteria. All selected studies were subsequently evaluated for quality assessment using the Jadad score [18].
Studies were excluded if they (i) enrolled fewer than 50 patients in the control arm, since small trials may be more likely to have biased estimates, (ii) did not report mortality by day 28 (± 2), (iii) were considered to be of poor quality (Jadad score < 3), (iv) used data from other RCTs or (v) were written in a language other than English. To minimise the risk of the results being influenced by the difference in disease classification, only trials using the first and second international consensus definition of sepsis were included [19].
The data extraction required for meta-analysis included the following information: (1) mortality at 28 ± 2 days, (2) number of patients enrolled in the usual care group, (3) number of patients in the intervention group, (4) whether or not the studied intervention had any beneficial effect on mortality, (5) age of the patients, (6) severity of condition at inclusion (defined as the average value of the APACHE II, SAPS II or SOFA score), (7) country, (8) author, (9) year of publication and (10) enrolment period.
To analyse temporal trends in severe sepsis and septic shock mortality, we performed a meta-regression analysis of the included trials pooled by year of first patient inclusion [20]. The temporal trend of mortality was modelled as:
$$ {\mathrm{mortality}}_i={\beta}_0+{\beta}_1\times {\mathrm{year}}_i+\varepsilon $$
where mortalityi is the mortality in the year i and β1 (slope) is the estimated temporal effect size per year on the pooled mortality. The same model was used to evaluate trends in age and disease severity. To reveal the effects of potential confounding factors, we also performed sensitivity analyses that included the average age of the patients as a dichotomous variable (< 65 vs. ≥ 65 years) in the meta-regression model.
The Higgins I2 was calculated to evaluate the statistical heterogeneity across the studies [21], with I2 > 30% considered as at least moderate heterogeneity. The pooled relative risk (RR) with corresponding 95% confidence interval (CI) was presented based on the random effects model. To investigate differences between the efficacy of different types of intervention, the trials were divided into eight subgroups and, accordingly, the RR were pooled within each subgroup.
The statistical analyses were performed in version 15.1 of Stata (Stata Corp., College Station, TX, USA). All statistical tests were two-sided. Overall combined RRs with 95% CIs and p values were calculated. Statistical significance was defined as a 95% CI excluding 0 or a RR excluding 1 and two-sided p < 0.05, except where otherwise specified.
This was a systematic review of previously published data from trials which had all been ethically approved before commencement, so no additional ethical approval was considered necessary.
Study characteristics
Of the 418 publications reviewed, 44 were included in the final analysis (Fig. 1 and Additional file 3: Table S2). These enrolled a total of 27,733 patients (13,315 patients in the usual care arm and 14,418 in the intervention arm) from 55 countries and 6 continents (Additional file 3: Table S2). Sorting the studies by date of first patient inclusion generated a time span of 22 years (1991–2013). Among the patients enrolled in the usual care arm, mean age was 62.7 (± 4.2) years, mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 22.4 (± 3.7), mean Simplified Acute Physiology Score (SAPS) II score was 52.9 (± 4.5) and mean Sequential Organ Failure Assessment (SOFA) score was 8.4 (± 2.1) (Table 1).
Flowchart showing the selection process of articles eligible for meta-analysis
Table 1 Geographic distribution and quality of the 44 included trials
Temporal trend of mortality
The meta-regression analysis showed a decrease in 28-day mortality of 0.42% per year (p = 0.04) between 1991 and 2013 (Fig. 2), giving a total decrease of 9.24% during the studied time period.
Regression analysis of the included sepsis trials regarding 28-day mortality. Studies are pooled by year of first patient enrolment. The size of the circle denotes the weight of the pooled mortality for each year
Subgroup analysis
A subgroup analysis with mean age modelled on a dichotomous variable (< 65 vs. ≥ 65 years) revealed that mortality was 8% higher in studies including patients with a mean age ≥ 65 years. Meta-regression of the mortality trend with adjustment for dichotomous age (< 65 vs. ≥ 65 years) still demonstrated a significant decline of 0.57% annually (95% CI − 0.010 to − 0.001; p = 0.01). APACHE II, SAPS II and SOFA scores on study inclusion were reported in 28, 14 and 24 studies, respectively (Additional file 3: Table S2). During the studied time period, there was a significant decline of 0.27 points annually in APACHE II score (p = 0.03) (Additional file 1: Figure S1). There was no trend of significance over time in the SAPS II and SOFA scores (p = 0.78 and p = 0.37, respectively). When adjusting the meta-regression analysis of the mortality over time for the three severity scores, the trend was no longer significant (adjusted p values for APACHE II, SAPS II and SOFA were 0.45, 0.23 and 0.98, respectively.
Efficacy of study interventions
The overall relative risk of mortality in the 44 included trials was 1.00 (95% CI 0.94 to 1.05). Four of the 44 trials showed the efficacy of the studied intervention with regard to 28-day mortality (Fig. 3). These four studies targeted the following interventions: selenium, talactoferrin, esmolol and ulinastatin [22,23,24,25]. A subgroup analysis of intervention efficacy, grouped by type of intervention, revealed a significantly higher relative mortality risk for the intervention in trials studying modulation of coagulation and inflammation [26,27,28,29,30,31] (RR = 1.113; 95% CI 1.019 to 1.216; p = 0.02; Table 2). This subgroup analysis included Higgin's I2 test to evaluate the potential heterogeneity in the selected subgroups. Three of the examined subgroups showed an I2 value over 30%. Only one group, the group called "Other interventions", did however show any heterogeneity of significance (p = < 0.001).
Forest plot displaying the relative mortality risks (RRs) of the interventions studied in the included sepsis trials. The individual points denote the RR of each study and the lines either side the 95% confidence intervals. The vertical line denotes the null effect
Table 2 Subgroup analysis for relative risk (RR) of intervention vs. control
In this study, we performed a meta-regression analysis of data derived from RCTs published between 2002 and 2016 (inclusion start date from 1991 to 2013) after a systematic literature search of studies including severe sepsis and septic shock. Our primary aim was to study the mortality trend of patients enrolled in the control arm. We found an annual decrease of 0.42% in the 28-day mortality among all patients enrolled as controls. Interestingly, the mortality trend was still a significantly decreasing one after adjustments for age and was found to be more pronounced in studies enrolling patients with a mean age ≥ 65 years. Severity scores were not adjusted for in our primary meta-regression analysis as different severity scores were used between the studies. However, when performing subgroup analyses with adjustments for APACHE II, SAPS II and SOFA scores on study inclusion, the mortality trend was no longer significantly decreasing over time. Consequently, the observed sepsis mortality decline in the control arm of RCTs could in part be explained by the inclusion of patients with a lower predicated mortality over time.
In the similar study from 2014 by Stevenson et al., also using data from sepsis patients included as controls of RCTs, a declining mortality trend by 3.0% annually was demonstrated [15]. The results of the unadjusted analysis in the present study support their results of a declining mortality trend in the control arm of sepsis trials, although an important difference was found as they demonstrated that the declining sepsis mortality was not confounded by changes in disease severity at inclusion. This might be due to differences in the inclusion and exclusion criteria of the studies entered in the meta-regression analysis. In particular, we included trials during a later time span and included studies enrolling patients who were ≥ 16 years old and excluded studies with poor quality. Additionally, Stevenson et al. performed adjustments of the meta-regression from estimations of predicted mortality derived from different severity assessment scales while we performed separate subgroup analyses. This might include errors as SAPS II and APACHE II are shown to differ in the prediction of hospital mortality [32].
Another important issue that should be discussed in relation to the study by Stevenson et al. is their final conclusion stating that a declining sepsis mortality over time in the control arm from RCTs supports the use of administrative data to monitor trends in sepsis mortality. In our opinion, this may be questioned as several studies comparing clinical data with administrative claims data have shown that the decreases in sepsis mortality over time shown by administrative data are overestimated [10,11,12,13].
The so-called Will Rogers phenomenon explains reduced disease-related mortality as a result of increased disease awareness and a higher proportion of less severely ill patients [33]. Indeed, the Will Rogers phenomenon could also be relevant in the current study due to changes in triage screening systems and to increased focus on early goal-directed treatment; as shown in a retrospective study on trends in usual care of septic shock patients between 2003 and 2013, time to initiation of antibiotics and fluid therapy in the emergency department was shown to be significantly shortened over time [34]. Several retrospective studies have demonstrated a clear association between early administration of antibiotic treatment and reduced sepsis mortality [35,36,37]. The results of these studies have led to the implementation of scoring systems for early identification of patients with suspected sepsis [38] and evidence-based treatment bundles. In 2002, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine implemented a new set of guidelines, the Surviving Sepsis Campaign, as an aid in the treatment of patients with severe sepsis and septic shock [39]. Medical centres following these guidelines to a higher degree have been shown to have a lower mortality in septic patients [40].
As a secondary aim of this study, we assessed the intervention effect on 28-day mortality. Overall, we found no efficacy regarding 28-day mortality. Four of the 44 included trials showed a beneficial effect of the studied intervention on mortality [22,23,24,25]. However, two of these interventions, which used selenium and talactoferrin respectively, failed to demonstrate any benefit when replicated in larger studies with multicentre settings [41, 42]. The other two treatment strategies with proven efficacy (esmolol and ulinastatin) [24, 25] have not yet been implemented in the guidelines for standard care of sepsis, as their clinical effect needs further evaluation, although ulinastatin has been described as a promising novel treatment option [43]. Our subgroup analysis of the interventions and their effect on mortality revealed a significant increase in relative risk in the group of interventions categorised as "modulation of coagulation and inflammation". All these trials investigated the effect of activated recombinant protein C (Xigris®). This result supports the reported risks of this specific treatment which led to its discontinuation [30].
As already established, sepsis is largely a heterogeneous syndrome. This diversity extends both to administrative aspects, leading to risks of classification errors, and to the pathobiology constituting the disease, creating a great variance in the presentation of the ailment based on properties of the pathogen and the host alike. The heterogeneity of patients included in RCTs investigating interventions for sepsis is probably an important reason for a large number of trials that have failed to prove efficacy. Although many post hoc analyses of large RCTs have been performed to control for this, including stratification to identify subgroups of patients who may benefit from the interventions that failed to prove efficacy, individualised treatments have not been implemented in clinical care [44]. Precision medicine with treatments guided by specific geno- or phenotypes seems to be a promising future approach to find interventions with efficacy in certain subgroups [45,46,47] but require molecular diagnostics with short turnaround to clinicians. Interestingly, four novel subtypes of sepsis based on routinely available clinical data, have recently been shown to predict for differences in treatment responses of previous sepsis trials [48].
In order to address the difficulties caused by the heterogeneity of the disease, in 2016, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine presented the third international consensus definition for sepsis and septic shock [49]. This aims to minimise the risk of misclassification and ease the management of the condition by presenting a more restricted definition of sepsis. This restricted definition may however increase the false negatives, as shown by Fang et al. [50]. It remains to be seen how this will affect heterogeneity in future studies, but hopefully this will ease the process of studying the disease, leading to a better understanding of the condition.
In recent decades, even though only a few specific interventions have shown some effect on mortality, progress has been made and embraced in the shaping of international guidelines. Several studies have raised a warning flag regarding excessive fluid therapy [51, 52], one of which reported a correlation between the amount of administered fluids and death [52], leading current guidelines to suggest a more restrictive approach [16]. Moreover, in 2012, Perner et al. reported an increase in adverse events while treating patients with septic shock with hydroxyethyl starch (a synthetic colloid) [53], with the result that it is no longer used in clinical management. Current guidelines advocate fluid resuscitation to be primarily constituted by crystalloids and, if needed, addition of albumin rather than any synthetic colloid [16]. Furthermore, improvements in sepsis survival in ICUs may be related to the use of a protective-ventilation strategy in patients with sepsis-induced acute respiratory distress syndrome, which correlates with increased survival [54].
Our study has several strengths. First, as this meta-analysis included over 13,000 patients enrolled in the control group in 44 trials from 55 countries and 6 continents, the reported results do not seem to be confined to a single part of the world. Moreover, all studies considered for inclusion were assessed for quality and excluded if they did not meet the pre-defined quality criteria. Lastly, as we used 28-day mortality ± 2 days as an inclusion criterion, the risk of missing important papers on the matter was reduced.
This study also has several important limitations. First, we only used one database to conduct our search and so may have left some studies out of our analysis. Second, the exclusion of trials published in languages other than English may have limited the findings of this meta-analysis to Western countries. Third, our choice to exclude trials assessed to be of poor quality may have further limited the number and diversity of the included trials. However, the limited number of trials excluded based on the quality assessment suggests that this is unlikely to have had any major impact on our results. Fourth, there might be differences related to the heterogeneity of the included sepsis trials as we included studies with severe sepsis and septic shock defined by either Sepsis-1 or Sepsis-2 criteria and from different parts of the world. Indeed, the degree and type of organ failure in sepsis are shown to be associated with the in-hospital mortality [10]. Unfortunately, heterogeneity is a problem in sepsis and septic shock that seems to be difficult to adjust for. Availability of individual patient-level data can be helpful in this matter. In the meta-analysis by de Grooth and colleagues, a great heterogeneity was found in the control arms of sepsis RCTs, although they only included septic shock patients [55]. This heterogeneity was only partly explained by differences in inclusion criteria and reported baseline characteristic. Interestingly, frequency, distributions and characteristics of the novel sepsis phenotypes identified by Seymour and colleagues were similar in studies with different definitions for sepsis [48]. Due to inconsistency in severity assessment scales and lack of individual patient-level data, we could only adjust for illness severity in subgroup analyses. However, the APACHE II score, which was the most commonly reported score, is an independent risk factor for mortality that contains important components of organ dysfunction [56]. The observation of inconsistency in severity assessment scales highlights the future importance of reporting disease severity by internationally adopted scores such as SOFA and SAPS III.
Finally, studies on trends in mortality from the usual care arm of sepsis trials may shed light on the history of sepsis research and partly mirror the trends in sepsis mortality, but are not suited for sepsis epidemiology surveillance due to the lack of clinical data and heterogeneity issues. The most reliable way to study trends in sepsis mortality seems to be based on clinical raw data derived from electronic healthcare data sets [10]. In a recent paper by Rhee et al., an adjusted version of the SOFA score, the "eSOFA", optimised for electronic health records, was shown to be of use as a tool in wide-scale surveillance of Sepsis-3 [57]. Hopefully, the initiatives from Centers for Disease Control and Prevention prioritising sepsis as a global health priority will aid governments and healthcare providers to find similar solutions outside the USA in order to the measure the true effects of interventions aiming to reduce the global burden of sepsis.
Data from RCTs showed a declining trend in 28-day mortality in severe sepsis and septic shock patients during the years from 1991 to 2013. However, when controlling for severity at study inclusion by APACHE II, SAPS II and SOFA scores, there was no significant change in mortality over time. Only 4 of the 44 included trials showed any efficacy with regard to mortality, and none of their methods have been implemented in the current treatment regimen of sepsis. Considering the unsuccessful history of RCTs aiming to lower sepsis mortality, it seems reasonable for future trials to focus on treatments targeted to certain subgroups and to use outcome measures beyond 28-day mortality.
Available upon request.
APACHE:
Acute Physiology and Chronic Health Evaluation
PICO:
Patient, Intervention, Comparison and Outcome
RCT:
Randomised controlled trial
SAPS:
Simplified Acute Physiology Score
SOFA:
Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, et al. Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit Care Med. 2016;193(3):259–72.
Liu V, Escobar GJ, Greene JD, Soule J, Whippy A, Angus DC, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014;312(1):90–2.
Paoli CJ, Reynolds MA, Sinha M, Gitlin M, Crouser E. Epidemiology and costs of sepsis in the United States—an analysis based on timing of diagnosis and severity level*. Crit Care Med. 2018;46(12):1889–97.
Rhee C, Jones TM, Hamad Y, Pande A, Varon J, O'Brien C, et al. Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Netw Open. 2019;2(2):e187571.
Kempker JA, Martin GS. The changing epidemiology and definitions of sepsis. Clin Chest Med. 2016;37(2):165–79.
Vincent J-L, Lefrant J-Y, Kotfis K, Nanchal R, Martin-Loeches I, Wittebole X, et al. Comparison of European ICU patients in 2012 (ICON) versus 2002 (SOAP). Intensive Care Med. 2018;44(3):337–44.
Fleischmann C, Thomas–Rueddel DO, Hartmann M, Hartog CS, Welte T, Heublein S, et al. Hospital incidence and mortality rates of sepsis. Dtsch Arztebl Int. 2016;113(10):159–66.
Kaukonen K-M, Bailey M, Bellomo R. Systemic inflammatory response syndrome criteria for severe sepsis. N Engl J Med. 2015;373(9):881.
Severe Sepsis and Septic Shock. N Engl J Med. 2013;369(21):2062–3.
Rhee C, Dantes R, Epstein L, Murphy DJ, Seymour CW, Iwashyna TJ, et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009–2014. JAMA. 2017;318(13):1241–9.
Rhee C, Murphy MV, Li L, Platt R, Klompas M, Centers for Disease Control and Prevention Epicenters Program. Improving documentation and coding for acute organ dysfunction biases estimates of changing sepsis severity and burden: a retrospective study. Crit Care. 2015;19:338.
Rhee C, Kadri S, Huang SS, Murphy MV, Li L, Platt R, et al. Objective sepsis surveillance using electronic clinical data. Infect Control Hosp Epidemiol. 2016;37(2):163–71.
Kadri SS, Rhee C, Strich JR, Morales MK, Hohmann S, Menchaca J, et al. Estimating ten-year trends in septic shock incidence and mortality in United States academic medical centers using clinical data. Chest. 2017;151(2):278–85.
Rhee C, Murphy MV, Li L, Platt R, Klompas M, Centers for Disease Control and Prevention Epicenters Program. Comparison of trends in sepsis incidence and coding using administrative claims versus objective clinical data. Clin Infect Dis. 2015;60(1):88–95.
Stevenson EK, Rubenstein AR, Radin GT, Wiener RS, Walkey AJ. Two decades of mortality trends among patients with severe sepsis: a comparative meta-analysis*. Crit Care Med. 2014;42(3):625–31.
Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304–77.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1–12.
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31(4):1250–6.
Thompson SG, Higgins JPT. How should meta-regression analyses be undertaken and interpreted? Stat Med. 2002;21(11):1559–73.
Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58.
Angstwurm MWA, Engelmann L, Zimmermann T, Lehmann C, Spes CH, Abel P, et al. Selenium in intensive care (SIC): results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock. Crit Care Med. 2007;35(1):118–26.
Guntupalli K, Dean N, Morris PE, Bandi V, Margolis B, Rivers E, et al. A phase 2 randomized, double-blind, placebo-controlled study of the safety and efficacy of talactoferrin in patients with severe sepsis. Crit Care Med. 2013;41(3):706–16.
Morelli A, Ertmer C, Westphal M, Rehberg S, Kampmeier T, Ligges S, et al. Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial. JAMA. 2013;310(16):1683–91.
Karnad DR, Bhadade R, Verma PK, Moulick ND, Daga MK, Chafekar ND, et al. Intravenous administration of ulinastatin (human urinary trypsin inhibitor) in severe sepsis: a multicenter randomized controlled study. Intensive Care Med. 2014;40(6):830–8.
Abraham E, Laterre P-F, Garg R, Levy H, Talwar D, Trzaskoma BL, et al. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med. 2005;353(13):1332–41.
Levi M, Levy M, Williams MD, Douglas I, Artigas A, Antonelli M, et al. Prophylactic heparin in patients with severe sepsis treated with drotrecogin alfa (activated). Am J Respir Crit Care Med. 2007;176(5):483–90.
Dhainaut J-F, Antonelli M, Wright P, Desachy A, Reignier J, Lavoue S, et al. Extended drotrecogin alfa (activated) treatment in patients with prolonged septic shock. Intensive Care Med. 2009;35(7):1187–95.
Shorr AF, Janes JM, Artigas A, Tenhunen J, Wyncoll DLA, Mercier E, et al. Randomized trial evaluating serial protein C levels in severe sepsis patients treated with variable doses of drotrecogin alfa (activated). Crit Care. 2010;14(6):R229.
Ranieri VM, Thompson BT, Barie PS, Dhainaut J-F, Douglas IS, Finfer S, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med. 2012;366(22):2055–64.
Annane D, Timsit J-F, Megarbane B, Martin C, Misset B, Mourvillier B, et al. Recombinant human activated protein C for adults with septic shock: a randomized controlled trial. Am J Respir Crit Care Med. 2013;187(10):1091–7.
Capuzzo M, Valpondi V, Sgarbi A, Bortolazzi S, Pavoni V, Gilli G, et al. Validation of severity scoring systems SAPS II and APACHE II in a single-center population. Intensive Care Med. 2000;26(12):1779–85.
Iwashyna TJ, Angus DC. Declining case fatality rates for severe sepsis: good data bring good news with ambiguous implications. JAMA. 2014;311(13):1295–7.
Hume PS, Varon J, Englert JA, Hurwitz S, Klompas M, Baron RM, et al. Trends in "usual care" for septic shock. Infect Control Hosp Epidemiol. 2018;39(9):1125–6.
Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589–96.
Kumar A, Ellis P, Arabi Y, Roberts D, Light B, Parrillo JE, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest. 2009;136(5):1237–48.
Ferrer R, Martin-Loeches I, Phillips G, Osborn TM, Townsend S, Dellinger RP, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med. 2014;42(8):1749–55.
Ghanem-Zoubi NO, Vardi M, Laor A, Weber G, Bitterman H. Assessment of disease-severity scoring systems for patients with sepsis in general internal medicine departments. Crit Care. 2011;15(2):R95.
Surviving Sepsis Campaign | History [Internet]. Available from: http://www.survivingsepsis.org/About-SSC/Pages/History.aspx. [cited 2019 Mar 12]
van Zanten ARH, Brinkman S, Arbous MS, Abu-Hanna A, Levy MM, de Keizer NF, et al. Guideline bundles adherence and mortality in severe sepsis and septic shock. Crit Care Med. 2014;42(8):1890–8.
Vincent J-L, Marshall JC, Dellinger RP, Simonson SG, Guntupalli K, Levy MM, et al. Talactoferrin in severe sepsis: results from the phase II/III oral talactoferrin in severe sepsis trial. Crit Care Med. 2015;43(9):1832–8.
Sakr Y, Maia VPL, Santos C, Stracke J, Zeidan M, Bayer O, et al. Adjuvant selenium supplementation in the form of sodium selenite in postoperative critically ill patients with severe sepsis. Crit Care. 2014;18(2):R68.
Linder A, Russell JA. An exciting candidate therapy for sepsis: ulinastatin, a urinary protease inhibitor. Intensive Care Med. 2014;40(8):1164–7.
Bentzer P, Fjell C, Walley KR, Boyd J, Russell JA. Plasma cytokine levels predict response to corticosteroids in septic shock. Intensive Care Med. 2016;42(12):1970–9.
Scicluna BP, van Vught LA, Zwinderman AH, Wiewel MA, Davenport EE, Burnham KL, et al. Classification of patients with sepsis according to blood genomic endotype: a prospective cohort study. Lancet Respir Med. 2017;5(10):816–26.
Davenport EE, Burnham KL, Radhakrishnan J, Humburg P, Hutton P, Mills TC, et al. Genomic landscape of the individual host response and outcomes in sepsis: a prospective cohort study. Lancet Respir Med. 2016;4(4):259–71.
Rello J, van Engelen TSR, Alp E, Calandra T, Cattoir V, Kern WV, et al. Towards precision medicine in sepsis: a position paper from the European Society of Clinical Microbiology and Infectious Diseases. Clin Microbiol Infect. 2018;24(12):1264–72.
Seymour CW, Kennedy JN, Wang S, Chang C-CH, Elliott CF, Xu Z, et al. Derivation, Validation, and Potential Treatment Implications of Novel Clinical Phenotypes for Sepsis. JAMA. Published online May 19, 2019321(20):2003–2017. https://doi.org/10.1001/jama.2019.5791.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801–10.
Fang X, Wang Z, Yang J, Cai H, Yao Z, Li K, et al. Clinical evaluation of Sepsis-1 and Sepsis-3 in the ICU. Chest. 2018;153(5):1169–76.
Marik PE, Linde-Zwirble WT, Bittner EA, Sahatjian J, Hansell D. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive Care Med. 2017;43(5):625–32.
Marik P, Bellomo R. A rational approach to fluid therapy in sepsis. Br J Anaesth. 2016;116(3):339–49.
Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med. 2012;367(2):124–34.
Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347–54.
de Grooth H-J, Postema J, Loer SA, Parienti J-J, Oudemans-van Straaten HM, Girbes AR. Unexplained mortality differences between septic shock trials: a systematic analysis of population characteristics and control-group mortality rates. Intensive Care Med. 2018;44(3):311–22.
Shankar-Hari M, Harrison DA, Rubenfeld GD, Rowan K. Epidemiology of sepsis and septic shock in critical care units: comparison between sepsis-2 and sepsis-3 populations using a national critical care database. Br J Anaesth. 2017;119(4):626–36.
Rhee C, Zhang Z, Kadri SS, Murphy DJ, Martin GS, Overton E, et al. Sepsis surveillance using adult sepsis events simplified eSOFA criteria versus Sepsis-3 sequential organ failure assessment criteria. Crit Care Med. 2019;47(3):307–14.
ALF funding is from Örebro University.
School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 70182, Örebro, Sweden
Robert Luhr, Bo Söderquist & Sara Cajander
Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182, Örebro, Sweden
Yang Cao
Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, 17177, Stockholm, Sweden
Department of Infectious Diseases, Örebro University Hospital, 70182, Örebro, Sweden
Bo Söderquist & Sara Cajander
Robert Luhr
Bo Söderquist
Sara Cajander
SC and BS conceptualised the study. RL constructed the search sequence. SC and RL sorted out eligible articles from the initial search and evaluated the quality of the included trials. RL extracted all the necessary data from the included trials. RL and SC jointly wrote the original draft of the manuscript. YC performed all the statistical analyses. All authors participated in writing and editing of the manuscript. All authors read and approved the final manuscript.
Correspondence to Sara Cajander.
Figure S1. Meta-regression analysis of the temporal trend in Acute Physiology and Chronic Health Evaluation (APACHE) II score between 1991 and 2013 in the included sepsis trials. (DOCX 88 kb)
Table S1. Search strategy. (DOCX 14 kb)
Table S2. Summary of data from trials included in meta-regression analysis. (DOCX 22 kb)
Luhr, R., Cao, Y., Söderquist, B. et al. Trends in sepsis mortality over time in randomised sepsis trials: a systematic literature review and meta-analysis of mortality in the control arm, 2002–2016. Crit Care 23, 241 (2019). https://doi.org/10.1186/s13054-019-2528-0
Severe sepsis
Septic shock


text:
Sigung Trent Sera Award
Maui Kajukenbo
Sifu Kristin
Sifu Kristin Kawahara began training under 6th degree black belt Sigung Trent Sera at Sera's Kajukenbo when the school first opened its doors in 1999. After graduating from high school, she moved to Oahu to study at the University of Hawaii - Manoa pursuing degrees in Japanese, music, and teaching. While at the University, Sifu Kristin studied the Reyes method of Kajukenbo under 9th degree black belt Grand Master Donald Crummer. Under Grand Master Don, she attained her black belt in 2004 and her 5th degree black belt in 2015.
In 2007, Sifu Kristin began training in Tae Kwon Do under Master Robert Farm, a student of Olympic Tae Kwon Do coach Master Dae Sung Lee.
Upon graduating from the University of Hawaii in 2009, Sifu Kristin returned to Maui and continued training and teaching under Sigung Trent Sera until his passing in 2012.
In September 2012, Sifu Kristin, Sifu Dominic, and Sifu Ed reopened the school under the new name "Maui Kajukenbo."
Sifu Kristin currently teaches both the Kids and Adult classes at their Kahului Location: Maui Family YMCA

redpajama_set_name: RedPajamaCommonCrawl


text:
Pilani Campus Home
Dept. of Computer Science and Information Systems
Page last updated on Tuesday, December 21, 2021
Prof. Mukesh Kumar Rohil, PhD (CSE)
Prof. Mukesh Kumar Rohil is currently an Associate Professor of Computer Science and Information Systems (CSIS) at BITS Pilani. He holds a Ph.D. (2004) in Computer Science & Engineering and an M.E. (1995) in Systems & Information from the Department of CSIS, BITS Pilani. Earlier, he graduated (1993) with a B.E. (Hons.) in Civil Engineering and an M.Sc. (Hons.) in Physics from BITS Pilani under its Dual Degree Programme. Dr. Rohil's research interests are wide-ranging and span a broad spectrum of domains. His research mainly focuses on Computer Vision, Artificial Intelligence, Multimedia, Extended Reality, Machine Learning, Human-Computer Interaction, Natural Language Processing, Geographical Information Systems and Software Engineering, and his secondary research interests include Data Mining, Business Analytics and Computer Networks. He leads the Multimedia and Human-Computer Interaction (MM-HCI) Laboratory of the Department of CSIS, BITS Pilani, Pilani Campus.
Prof. Rohil's research has been funded by the government as well as industries in India and abroad. He has received a major sponsored research project on "Support for Entrepreneurial and Managerial Development of SMEs through Incubators" from the Ministry of Micro, Small and Medium Enterprises (MSME), Government of India, New Delhi, and a minor research grant from the University Grants Commission (UGC), New Delhi. He has executed and coordinated several industry-sponsored major research and developmental projects for the Technology Innovation Centre (TIC) of BITS Pilani. He has executed the sponsored TIC projects titled "Enhanced Training Capabilities through Video 'YouTube like' Technology" for Sabre Travel Network, Bengaluru (Subsidiary of Sabre Corporation, Southlake, TX, USA), and "Augmented Reality for Maintenance and Repair" and "Semantic Technology Research" for John Deere, Pune, besides coordinating few other sponsored TIC projects for Sabre Travel Network, Bengaluru and RedMed Health Systems, Bengaluru. Dr. Rohil has also completed a couple of externally funded consultancy projects pertaining to Management Information Systems, apart from accomplishing several in-house projects at BITS Pilani. Having published a number of research articles (~50) in several refereed international/national journals, conferences, conventions, workshops and symposia of repute published/organized by ACM, IEEE, Springer, Taylor & Francis, ISPRS, IET, ISRS and Indian Buildings Congress amongst others, Prof. Rohil has been an active reviewer to leading journals like IEEE Transactions on Geoscience and Remote Sensing, IEEE Geoscience and Remote Sensing Letters, Multimedia Tools and Applications (Springer) and Journal of the Indian Society of Remote Sensing (Springer). He is a Life Member of the Indian Society of Remote Sensing. He has delivered several invited keynote and research talks at national venues. He has independently supervised three Ph.D. students, and is currently supervising four doctoral scholars. He has also (been) proactively served (serving) as a Doctoral Advisory Committee (DAC) Member for seven Ph.D. students, and has been an external examiner for several doctoral theses and master's degree dissertations as well. In addition, he has supervised more than 40 Higher Degree Dissertations/Research Practices/Studies in Advanced Topics and 150 First Degree Theses/Projects, and has taught varied courses (26 in total) in CSIS and allied interdisciplinary areas over time at BITS Pilani.
As Nucleus Member of the Work Integrated Learning Programmes (WILP) Division for over 14 years till August 2018, Dr. Rohil was entrusted to accomplish multi-skilled tasks as a Team Lead for Software Development, managing a multi-site IT infrastructure for about 150 employees and 20,000 students and a proactive team member responsible for delivering superior quality, customer-focused and industry-aligned academic IT services. As Team Lead for the Task Force on WILP Process Excellence Imperative under BITS Pilani's Mission 2012 - Vision 2020, he envisioned and led the innovative creation (from idea to implementation) of 'E-Assess', the first-of-a-kind digital evaluation solution which transformed the scenario of evaluation for WILP and remains till date a benchmark for fully-digital evaluation of like volumes of answer booklets. He also led the team that designed and developed one of BITS Pilani's largest Management Information Systems for its WILP Division (then Distance Learning Programmes Division) during 1996-1998. Being a proactive member in industry personnel training and delivering software solutions to various industries during 1995-2004, Prof. Rohil has been highly instrumental in fostering the Industry Engagement for BITS Pilani.
Contact Coordinates
Prof. Mukesh Kumar Rohil
Room No. 6120-H
Department of Computer Science and Information Systems
BITS Pilani, Pilani Campus
Vidya Vihar, Pilani - 333031
Email: rohil@pilani.bits-pilani.ac.in
Phone (Direct): +91-1596-255615
Phone (Department): +91-1596-255405
Profile Webpage: www.bits-pilani.ac.in/~rohil
Sponsored Research and Consultancy Projects
Keynotes, Research Talks and Chaired Sessions
Administrative and Institutional Responsibilities
Multimedia and HCI Laboratory


Louis Armstrong was the first important soloist to emerge in jazz and he became the most influential musician in the music's history. As a trumpet virtuoso his playing, beginning with the 1920s studio recordings made with his Hot Five and Hot Seven ensembles, charted a future for jazz in highly imaginative, emotionally charged improvisation. For this, he is revered by jazz fans. But Armstrong also became an enduring figure in popular music due to his distinctively phrased bass singing and engaging personality, which were on display in a series of vocal recordings and film roles. Given his popularity, his long career, and the extensive label-jumping he did in his later years, as well as the differing jazz and pop sides of his work, his recordings are extensive and diverse, with parts of his catalog owned by many different companies.
Armstrong made his recording debut as a leader on November 12, 1925. Contracted to OKeh Records, he began to make a series of recordings with studio-only groups called the Hot Fives or the Hot Sevens. By February 1927, Armstrong was well-enough known to front his own group, Louis Armstrong & His Stompers. In April, he reached the charts with his first vocal recording, "Big Butter and Egg Man," a duet with May Alix. By the start of 1932, he had switched from the "race"-oriented OKeh label to its pop-oriented big sister Columbia Records, later moving to Decca. He also took a series of small parts in motion pictures, beginning with Pennies From Heaven in December 1936. With the decline of swing music in the post-World War II years, Armstrong broke up his big band and put together a small group dubbed the All Stars, which made its debut in Los Angeles on August 13, 1947. Armstrong completed his contract with Decca in 1954, after which his manager made the unusual decision not to sign him to another exclusive contract but instead to have him freelance for different labels. In 1964, he scored a surprise hit with his recording of the title song from the Broadway musical Hello, Dolly!, which reached number one in May. This pop success was repeated internationally four years later with "What a Wonderful World," which hit number one in the U.K. in April 1968. He performed less frequently in the late '60s and early '70s and died of a heart ailment at 69.


A New York Times Bestselling AuthorA Lynley NovelInspector Thomas Lynley of Scotland Yard and the pugnacious and deeply loyal Sergeant Barbara Havers find themselves up against one of the most sinister murder cases they have ever encountered. Both a page-turner and a deeply complex story about the lies we tell, the lies we believe, and the redemption we need, this novel will be remembered as one of George's best.
Elizabeth George is the author of highly acclaimed novels of psychological suspense. She won the Anthony and Agatha Best First Novel awards in America and received the Grand Prix de Litterature Policiere in France. In 1990 she was awarded the prestigious German prize for international mystery fiction, the MIMI. Her novels have now been adapted for television by the BBC. An Edgar and Macavity Nominee as well as a New York Times and international bestselling author, Elizabeth George lives on Whidbey Island in the state of Washington.


text:
package com.microsoft.azure.cognitiveservices.search.newssearch.models;

import com.fasterxml.jackson.annotation.JsonProperty;
import com.fasterxml.jackson.annotation.JsonTypeInfo;
import com.fasterxml.jackson.annotation.JsonTypeName;

/**
 * Defines a video object that is relevant to the query.
 */
@JsonTypeInfo(use = JsonTypeInfo.Id.NAME, include = JsonTypeInfo.As.PROPERTY, property = "_type", defaultImpl = VideoObject.class)
@JsonTypeName("VideoObject")
public class VideoObject extends MediaObject {
    /**
     * The motionThumbnailUrl property.
     */
    @JsonProperty(value = "motionThumbnailUrl", access = JsonProperty.Access.WRITE_ONLY)
    private String motionThumbnailUrl;

    /**
     * The motionThumbnailId property.
     */
    @JsonProperty(value = "motionThumbnailId", access = JsonProperty.Access.WRITE_ONLY)
    private String motionThumbnailId;

    /**
     * The embedHtml property.
     */
    @JsonProperty(value = "embedHtml", access = JsonProperty.Access.WRITE_ONLY)
    private String embedHtml;

    /**
     * The allowHttpsEmbed property.
     */
    @JsonProperty(value = "allowHttpsEmbed", access = JsonProperty.Access.WRITE_ONLY)
    private Boolean allowHttpsEmbed;

    /**
     * The viewCount property.
     */
    @JsonProperty(value = "viewCount", access = JsonProperty.Access.WRITE_ONLY)
    private Integer viewCount;

    /**
     * The thumbnail property.
     */
    @JsonProperty(value = "thumbnail", access = JsonProperty.Access.WRITE_ONLY)
    private ImageObject thumbnail;

    /**
     * The videoId property.
     */
    @JsonProperty(value = "videoId", access = JsonProperty.Access.WRITE_ONLY)
    private String videoId;

    /**
     * The allowMobileEmbed property.
     */
    @JsonProperty(value = "allowMobileEmbed", access = JsonProperty.Access.WRITE_ONLY)
    private Boolean allowMobileEmbed;

    /**
     * The isSuperfresh property.
     */
    @JsonProperty(value = "isSuperfresh", access = JsonProperty.Access.WRITE_ONLY)
    private Boolean isSuperfresh;

    /**
     * Get the motionThumbnailUrl value.
     *
     * @return the motionThumbnailUrl value
     */
    public String motionThumbnailUrl() {
        return this.motionThumbnailUrl;
    }

    /**
     * Get the motionThumbnailId value.
     *
     * @return the motionThumbnailId value
     */
    public String motionThumbnailId() {
        return this.motionThumbnailId;
    }

    /**
     * Get the embedHtml value.
     *
     * @return the embedHtml value
     */
    public String embedHtml() {
        return this.embedHtml;
    }

    /**
     * Get the allowHttpsEmbed value.
     *
     * @return the allowHttpsEmbed value
     */
    public Boolean allowHttpsEmbed() {
        return this.allowHttpsEmbed;
    }

    /**
     * Get the viewCount value.
     *
     * @return the viewCount value
     */
    public Integer viewCount() {
        return this.viewCount;
    }

    /**
     * Get the thumbnail value.
     *
     * @return the thumbnail value
     */
    public ImageObject thumbnail() {
        return this.thumbnail;
    }

    /**
     * Get the videoId value.
     *
     * @return the videoId value
     */
    public String videoId() {
        return this.videoId;
    }

    /**
     * Get the allowMobileEmbed value.
     *
     * @return the allowMobileEmbed value
     */
    public Boolean allowMobileEmbed() {
        return this.allowMobileEmbed;
    }

    /**
     * Get the isSuperfresh value.
     *
     * @return the isSuperfresh value
     */
    public Boolean isSuperfresh() {
        return this.isSuperfresh;
    }

}

redpajama_set_name: RedPajamaGithub


text:
from ceph_deploy import cli
from ceph_deploy.tests import util

class FakeLogger(object):

    def __init__(self):
        self._calls = []
        self._info = []

    def _output(self):
        return '\n'.join(self._calls)

    def _record(self, level, message):
        self._calls.append(message)
        method = getattr(self, '_%s' % level)
        method.append(message)

    def info(self, message):
        self._record('info', message)

class TestLogFlags(object):

    def setup(self):
        self.logger = FakeLogger()

    def test_logs_multiple_object_attributes(self):
        args = util.Empty(verbose=True, adjust_repos=False)
        cli.log_flags(args, logger=self.logger)
        result = self.logger._output()
        assert ' verbose ' in result
        assert ' adjust_repos ' in result

    def test_attributes_are_logged_with_values(self):
        args = util.Empty(verbose=True)
        cli.log_flags(args, logger=self.logger)
        result = self.logger._output()
        assert ' verbose ' in result
        assert ' : True' in result

    def test_private_attributes_are_not_logged(self):
        args = util.Empty(verbose=True, _private='some value')
        cli.log_flags(args, logger=self.logger)
        result = self.logger._output()
        assert ' _private ' not in result


As we head into the first official week of February, it can only mean one thing: the Oscars will be here before you know it.
In honour of Tinseltown's biggest night, the iconic Cinesphere theatre at Ontario Place will be screening the best Hollywood movies from 2017 over the next month, just in time for the Oscars.
Because there really is no better place to experience the most critically-acclaimed films of 2017 than in Toronto's famous geodesic dome, where the movie-going experience is unlike anything else in the city.
The Cinesphere has been an iconic landmark in Toronto for almost half a century and is now a year-round destination, where movie lovers of all ages can enjoy a film on the big screen.
Starting this weekend, Cinesphere will screen the Best of Hollywood 2017 in IMAX digital laser and IMAX 70mm film technologies, providing viewers the unique opportunity to see the best films in their purest form.
The lineup includes Lady Bird, Call Me By Your Name, Get Out, The Florida Project, The Big Sick, Wonder Woman, Dunkirk, and Blade Runner 2049.
The full list of showtimes can be found here.


text:
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Woodbridge, VA (22192)
Occasional snow showers. High 36F. Winds NNW at 10 to 20 mph. Chance of snow 40%..
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Resurgence in Fairfax jobs picture seems to hit a sticking point
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[Sun Gazette Newspapers provides content to, but otherwise is unaffiliated with, InsideNoVa or Rappahannock Media LLC.]
Like much of Northern Virginia, Fairfax County's jobless rate has improved substantially from the depths of the COVID crisis a year before, but now seems struck in neutral as it attempts to return to pre-pandemic lows.
With a total of 594,803 county residents employed in the civilian workforce and 22,702 looking for jobs, Fairfax's jobless rate of 3.7 percent in May was up a tick from 3.6 a month before, according to figures reported June 30 by the Virginia Employment Commission.
The jobless rate was, however, a significant improvement from a year before, as the impact of government-imposed economic lockdowns was beginning to take hold. Fairfax County's jobless rate in May 2020 stood at 8.1 percent, according to state officials.
Most localities across Northern Virginia were in the same boat as Fairfax, with their jobless rates much better than a year before but still struggling to get back to pre-pandemic levels.
Jobless rates for the month stood at 2.8 percent in Falls Church, up from 2.6 percent a month before; 3.1 percent in Arlington, unchanged; 3.3 percent in Loudoun County, up from 3.1 percent; 3.9 percent in Alexandria, down from 4 percent; and 4.2 percent in Prince William County, up from 4.1 percent.
For Northern Virginia as a whole, the jobless rate of 3.7 percent in May was up from 3.5 percent in April, representing 1.56 million residents employed in the civilian workforce and 59,300 looking for jobs.
Among Virginia's 134 cities and counties, the lowest joblessness was found in Madison County, at 2.5 percent, followed by Falls Church and then a tie at 2.9 percent between King George and Rappahannock counties. The highest rates were found in Petersburg (10.6 percent), Martinsville and Hopewell (7.8 percent each), and Emporia (7.7 percent).
Virginia's statewide, non-seasonally-adjusted unemployment rate of 4.1 percent in May was down from 3.9 percent in April, but kept Virginia well below than the national average of 5.5 percent.
Among the 50 states, the lowest jobless rates for the month were recorded in New Hampshire (2.5 percent) and Nebraska and Vermont (2.6 percent each). The highest rates were found in Hawaii (8.1 percent), New Mexico (8 percent) and California (7.9 percent).
Over the past year, Virginia has gained back about 255,000 jobs lost in the early part of the pandemic, up about 7 percent in total jobs. Nationally, Nevada has seen the biggest rebound (up 19.2 percent in employment since May 2020), followed by Michigan (up 16.8 percent) and Rhode Island (13 percent). In raw numbers, the biggest rebound in jobs was found in California (up 1.22 million from the depths of COVID), New York (882,500) and Texas (804,200).
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text:
Kid Cudi teams up with Nigo for euphoric new track 'Want It Bad'
It's the latest preview of the Bape founder's upcoming album
By Will Lavin
Kid Cudi and Nigo. CREDIT: YouTube/Kid Cudi
Kid Cudi has teamed up with DJ and Bape founder Nigo for a brand new single called 'Want It Bad' – listen to it below.
READ MORE: Kid Cudi – 'Man On The Moon III: The Chosen' review: an art piece of epic highs and honest lows
Produced by Pharrell, it's the second preview of Nigo's upcoming album, 'I Know Nigo'. The first track to be released from the project was last month's A$AP Rocky-featured 'Ayra'.
On the euphoric 'Want It Bad', Cudi celebrates his successes and the grind it took to get to this point: "Lives fast, with high hopes/ Story of a kid who was feelin' low/ To the life of me, lemme set the scene/ On my grind, I work hard/ Lord hit me, woah, tell 'em it's a new mould/ Walk into a different zone, doin' the impossible/ Too incredible."
Arriving with a flashy video shot in Paris, you can check out the Harrison Boyce-directed clip below:
Nigo first announced the forthcoming album back in December, revealing that the project was on the way and that he'd signed to Steven Victor's Victor Victor Worldwide label, a joint venture between Victor and Universal Music Group.
Guest appearances will include Pharrell, Kid Cudi, A$AP Rocky, Lil Uzi Vert, Pusha T, Tyler, The Creator, Fam-Lay and Teriyaki Boyz, with more to be announced.
Outside of his work as the head of the streetwear brand A Bating Ape, Nigo has long had an interest and association with the world of music. He is the DJ for hip hop collective Teriyaki Boyz, who released debut album 'Beef or Chicken' in 2005 and follow-up 'Serious Japanese' in 2009.
Numerous artists that will feature on Nigo's forthcoming album have appeared on previous Teriyaki Boyz cuts – Williams on 'Cho L A R G E' and 'Work That!', Pusha T and Fam-Lay on a remix of 'Tokyo Drift (Fast & Furious)'.
'Want It Bad' is Cudi's first new music of 2022. His last album was 2020's 'Man On The Moon III: The Chosen'.
In a four-star review of the album, NME's Will Lavin called it a "cinematic masterstroke that electrifies the senses at every turn".
The review continued: "Kid Cudi gives us every part of himself, laying out his insecurities and inner demons in the hope that it might help someone else, his words etched into a vivid backdrop of intoxicating melodies and palatial riffs. No one does mood music quite like Cudi."
Kid Cudi. CREDIT: Edward Berthelot/Getty Images
In December, the vinyl version of the album broke a US chart record, re-entering the Billboard chart at Number Four, surpassing its previous peak of Number 10. In the week beginning December 17, the album sold 42,000 copies, 41,500 of which were on vinyl.
According to Chart Data, this means the album has broken the record for biggest vinyl sales week for both a male artist and a rap album in Nielsen history.
Meanwhile, Cudi has revealed plans to drop two separate albums this year, saying he has some "tasty surprises".


text:
Q: String concat in C void xsdValidation(char *xsdName, char *xmlName){
 char *terminalCommand;
 system("xmllint --noout --schema ", xsdName , xmlName);
}

I have a little problem with that. I have a code to valide my xml. And my xml's name and xsd's name came from as a argument. How can i concat these 3 things?

A: Use snprintf():
/* determine buffer size */
int len = snprintf(NULL, 0, "xmllint, --noout --schema %s %s", xsdName, xmlName);
if (len < 0) {
    /* error handling for EILSEQ here */
}

char *buf = malloc(len + 1);
if (buf == NULL) {
    /* err handling for malloc() failure here */
}

snprintf(buf, (size_t)len, "xmllint, --noout --schema %s %s", xsdName, xmlName);

system(buf);
free(buf);

On a sufficiently recent system, you could also use asprintf() to greatly simplify this code:
char *buf = NULL;
asprintf(&buf, "xmllint, --noout --schema %s %s", xsdName, xmlName);
if (buf == NULL) {
    /* error handling here */
}

system(buf);
free(buf);

Note that all these approaches fail if xsdName or xmlName contain spaces or other special characters. You might want to invoke an exec function directly to avoid that problem.

A: You can use strcat() to concat strings.
void xsdValidation(char *xsdName, char *xmlName){
 static const char *xmlLint = "xmllint --noout --schema ";
 /* do not forget to +1 for terminating null character */
 char *terminalCommand = malloc(strlen(xmlLint) + strlen(xsdName) + strlen(xmlName) + 1);
 if(terminalCommand != NULL){
  strcpy(terminalCommand, xmlLint); /* use strcpy() here to initialize the result buffer */
  strcat(terminalCommand, xsdName);
  strcat(terminalCommand, xmlName);
  system(terminalCommand);
  free(terminalCommand);
 }
}

This may improve performance a little because it reuse the calculated length.
void xsdValidation(char *xsdName, char *xmlName){
 static const char *xmlLint = "xmllint --noout --schema ";
 size_t xmlLintLen = strlen(xmlLint);
 size_t xsdNameLen = strlen(xsdName);
 size_t xmlNameLen = strlen(xmlName);
 /* do not forget to +1 for terminating null character */
 char *terminalCommand = malloc(xmlLintLen + xsdNameLen + xmlNameLen + 1);
 if(terminalCommand != NULL){
  /* use strcpy() to copy the strings */
  strcpy(terminalCommand, xmlLint);
  strcpy(terminalCommand + xmlLintLen, xsdName);
  strcpy(terminalCommand + xmlLintLen + xsdNameLen, xmlName);
  system(terminalCommand);
  free(terminalCommand);
 }
}

A: If the compiler supports variable length arrays then you may write
void xsdValidation( const char *xsdName, const char *xmlName )
{
    const char *command = "xmllint --noout --schema ";
    char terminalCommand[strlen( command ) + strlen( xsdName ) + strlen( xmlName ) + 2];

    strcpy( terminalCommand, command );
    strcat( terminalCommand, xsdName );
    strcat( terminalCommand, " " );
    strcat( terminalCommand, xmlName );

    system( terminalCommand );
}

Otherwise you should to allocate the required array dynamically. For example
void xsdValidation( const char *xsdName, const char *xmlName )
{
    const char *command = "xmllint --noout --schema ";
    char *terminalCommand =
        malloc( strlen( command ) + strlen( xsdName ) + strlen( xmlName ) + 2 );

    if ( terminalCommand != NULL )
    {
        strcpy( terminalCommand, command );
        strcat( terminalCommand, xsdName );
        strcat( terminalCommand, " " );
        strcat( terminalCommand, xmlName );

        system( terminalCommand );

        free( terminalCommand );
    }
}

redpajama_set_name: RedPajamaStackExchange


text:
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First Annual American College of CBD & Cannabis Congress Designed to Enhance Physicians' Knowledge
Cannabis News 11/01/2019 Carol Felix 0
By Vanessa Orr Every day, people are going into their doctors' offices and asking about medical cannabis and CBD. Finding answers, however, isn't so...
By Vanessa Orr
Every day, people are going into their doctors' offices and asking about medical cannabis and CBD. Finding answers, however, isn't so easy.
"Medical cannabis is a growing, $5 billion industry, and nationally, CBD is already a $2 billion industry, yet there are no CBD-focused medical societies that can help clinicians learn about it," said Jordan Desnick, founder of the American College of CBD & Cannabis (ACCC). "Physicians don't learn about CBD or cannabis in medical school, or during their internships or residencies, but patients are asking about it on a daily basis, and the lack of knowledge puts both physicians and patients at risk."
The American College of CBD & Cannabis (ACCC) serves as an educational platform for physicians and allied healthcare professionals to discuss and learn about the medical benefits of cannabidiol (CBD) and medicinal cannabis. The ACCC supports clinicians in their practices and helps them optimize the medical benefits of CBD and medicinal cannabis for their patients.
"The potential opportunities for physicians in the CBD realm are enormous," added Desnick. "If they can recommend over-the-counter products for anxiety, sleep disorders, spasticity, drug addiction and the like, instead of ordering strong prescription medicines for the same symptoms, that's a significant health benefit for their patients."
"Twenty years ago, Viagra came out, and was a blockbuster drug for Pfizer," added ACCC Medical Consultant Jim Desnick, M.D. "Now it's a billion-and-a-half-dollar drug. CBD already exceeds $1.5 billion in sales and is projected in the next five years to become a $22-25 billion industry. The need for physicians to be educated about CBD is extremely important."
According to Jim Desnick, physicians are showing an increased interest in recommending CBD products to their patients.
"In Florida, there are approximately 2,500 physicians licensed to prescribe marijuana, but less than a couple hundred are doing it. Many of them are not ready to go the medical cannabis route, but are dipping their toes into the CBD arena," he explained.
"Think of the tens of thousands of primary care physicians who are being asked about CBD by their patients, but have no science-based knowledge," added Jordan Desnick. "Establishing the ACCC was necessary to fill this void and to create a professional medical society to not only provide CBD education, but credential physicians to show their knowledge and legitimacy in this space."
On Saturday and Sunday, March 14-15, 2020, the ACCC is hosting the first annual American College of CBD & Cannabis Spring Congress for primary care physicians and allied health professionals. Keynote speakers will include Eugene Scharf, M.D., a neurologist at the Mayo Clinic Rochester and assistant professor of neurology, and Peter Grinspoon, M.D., an internist at Mass General Hospital and instructor at Harvard Medical School, who also authored the book, Free Refills: A Doctor Confronts His Addiction.
"Each day, there will be seven or eight sessions presented by leading physicians and educators in the CBD/cannabis world," said Jordan Desnick. "Topics will range from the biology of the endocannabinoid system, to medical indications for CBD, to proper dosing and CBD's interaction with other commonly prescribed medications like blood thinners."
"We will also have presentations by top attorneys who will talk about CBD and medical cannabis from a legal perspective," added Jim Desnick. "While the legalities of medical cannabis are fairly black and white, CBD is still a gray area. Physicians want to know if they can recommend it, or if they can dispense it from their offices. There is also the state vs. federal aspect of the regulatory landscape, which complicates matters even more."
The event, which will be held at the Rosen Shingle Creek Resort in Orlando, FL, will also feature a number of vetted exhibitors, showcasing third-party, lab-tested products. Tickets to the event are available at www.ACCBD.com and participants can earn up to 14 CME credits by attending. Group hotel rates and early-bird discounts are available.
MedMen Announces Additional US $10 Million Senior Secured Convertible Note Financing Under Gotham Green Facility
Cannabis News Jan 15, 2021 0
Trulieve Opens Second Location in Gainesville
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This has sure been some amazing week for video games now hasn't it? Not only for the industry but also for us over here as it was another heavy review week with things from Horizon Zero Dawn to The Walking Dead and a few others in between. We also had a lot of cool things to see for Injustice 2 again and more for Prey as both of those titles get even closer to releasing next month. More video games to play and not enough time to do it. Not a horrible problem to have unless you have a wallet that cries itself to sleep every night. But let's focus on the positive here instead of the responsible.
While this week was riddled with many reviews, that was not all of the video games we have out there right now, I know of at least two more we have cooking up for you and you'll want to see those. I am also certain that we are going to start hearing a whole lot more on Project Scorpio now that the specs have been given out. Factor in all of the huge events coming up soon and we will be insanely crazy busy again. With all those video games and their news it is a good thing that we have some extra staff on board here. Which, if you are interested, send over a message and we'll see about getting you into our little slice of weird video games over here.


text:
Producers Guild of America (PGA) é uma associação comercial que representa produtores de cinema, televisão e mídias diversas dos Estados Unidos. A comunidade do PGA inclui mais de 7000 membros de inúmeros estúdios de produção midiática de todo o mundo. Com sede em Los Angeles, os atuais presidentes são Gary Lucchesi e Lori McCreary.

Em 1991, o Producers Guild of America criou o Laurel Awards, renomeado Producers Guild Awards em 2002, que condecora os melhores filmes e séries do ano anterior.

Ligações externas

Produtores da América
Organizações fundadas em 1962
Produtores de cinema dos Estados Unidos
Produtores de televisão dos Estados Unidos
Prémios do Sindicato dos Produtores da América
Cultura de Los Angeles

redpajama_set_name: RedPajamaWikipedia


At St. Michael, Kidventure strives to create an environment that provides all students, from Early Childhood to 8th grade, an amazing place to finish their day. Finale emphasizes the importance of academics, sportsmanship, respect for oneself, respect for others and respect for our community through fun, active, and engaging curriculum. You can find us studying, conducting science experiments, channeling our inner Picasso or playing games in the gym or on the field and playground!
Finale After School 3:00 – 6:00 p.m. 3:00 – 6:00 p.m. 2:00 – 6:00 p.m. 3:00 – 6:00 p.m. 3:00 – 6:00 p.m.
Please refer to the school's calendar to determine any schedule disruptions. Finale After School will not take place on any half days or holidays.
It is encouraged to create an account, even if Finale is not used on a regular basis. In the event your child needs to come to After School, this gives us all information needed for your student, along with making the check out process easier for you.
Fall Semester (Aug – Dec) $950.00 Payment is due in full upon registration.
Fall Semester Payment Plan (Aug – Dec) $1,050.00 A 10% deposit and 4 monthly installments due before the 25th of each month.
Spring Semester (Jan – May) $1,175.00 Payment is due in full upon registration.
Spring Semester Payment Plan (Jan – May) $1,300.00 A 10% deposit and 5 monthly installments due before the 25th of each month.
Daily Rate $25.00/ day** Day(s) used will automatically be charged at the end of the month for all usage.
*There is a one time $10.00 registration fee for each student per school year.
End of the month for all usage.
For each semester payment plan a 10% deposit is required with each monthly installment due on the 25th of the month. If switching from the semester rate to another option, please contact the office for assistance.
Daily usage will be tracked and will be automatically charged at the end of the month for all days used throughout that month. It is encouraged to create an account before your child attends their first day. If you participate in a Finale session that you are not registered for, the credit card on file will be billed for your usage of the program. Failure to pay or make alternate arrangements with our office will result in your student not being allowed in to the Kidventure After School program until payment has been received.
*Refunds, transfers & payment plans of sessions may be granted on a case-by-case basis pending a written approval of the Kidventure office and the parent. Prorated rates are not available for Finale sessions.
You may pick up your child at any time during After School's normal operating hours.
Where will my child be?
A $1 per minute late fee will be charged after 6:00 p.m., cash or check, payable directly to the Finale staff members that have remained with your child. Finale staff will never leave a child unattended. Habitual lateness may result in an increase in the $1.00/min/child late fee payment or expulsion from the Kidventure After School Program.
Who can pick up my child?
Parents and legal guardians are authorized to pick up their child. Persons listed on your child's registration form as additionally authorized will also be able to pick up your child. Please be prepared to show ID to Finale After School staff to ensure the safe release of your child.
If it is necessary for someone not listed on your registration form to pick up your child, please alert the Program Coordinator, Taylor, in advance so they can be added to your list of authorized pick up persons. Finale After School staff will need to know the name of the person who will be picking up your child, and will need to see their ID at pick up.
Parents are welcome to visit the Finale program at any time during normal hours without prior notice or approval to observe their child, observe the operation and/or program activities.
Finale After School provides a snack and water to every child every day. Snacks are purchased through Labatt Food Services and are peanut and peanut byproduct free. Snacks will also be based on kashrut guidelines and approved by the school prior to distribution to the students.
We understand that children are tired after a long day of school, but the same courtesy and respect practiced throughout the day should remain consistent in the After School Program. Kidventure's disciplinary action is a three strike system, which is age appropriate.
Strike 1: Warning, Explanation of Possible Consequence.
Time out of 1 minute per age, sentences, sit out of activity, etc.
Explanation of parent call if rule broken again.
We work closely with the school and principal when handling discipline and conduct issues, in order to coordinate and universally enforce the same standards and expectations of all students.
If your child will be taking medications of any kind* during Finale, you must complete and submit an After School Medical Dosage Form. The form must be submitted to the Lead Counselor on-site with the medication in its original container before medication can be dispensed. This includes over-the-counter medicines to be taken as needed, such as Tylenol or Benadryl.
All medications will be dispensed only by the Lead Counselor per doctor instructions and your instructions.
*Kidventure does not administer shots. If your child needs medication or insulin injections during Finale After School, you or another authorized party must come to the school to administer them when needed. We will aid in checking blood levels with retractable needles.
In the event of severe weather or any other potentially threatening situation, Finale will make every effort to notify you immediately regarding your child(ren)'s safety. Please ensure all contact information you provide us with is correct and up-to-date. If cancellation of Finale After School due to these circumstances becomes necessary, we will announce any cancellations in conjunction with the school via email.
From time to time, children may become ill or may not feel well. We maintain a designated First Aid/Sick Station where the sick child will be isolated from the other children and allowed to rest. If your child is sick, we will notify you, and in some cases we will ask you to pick up your child.
All Finale staff members are First Aid and CPR certified and will follow appropriate protocol according to the Kidventure Emergency Operations Plan and their First Aid and CPR Certifications. Parents will be notified by phone immediately of major medical incidents. Minor injuries and incidents will be communicated to parents either by phone or upon pick up.
Computers and calculators are allowed in the After School Program for purposes of completing homework. However, we strongly discourage the possession of personal gaming devices (Nintendo DS, PSP, etc.), cell phones, iPods and any similar electronic devices not used for educational purposes.
Kidventure's Finale After School program is licensed by the Texas Department of Family and Protective Services (DFPS) as a Before and After School Program. We adhere to the Minimum Standards set forth by DFPS, which outline all minimum standards that Before and After School programs must follow. We are also subject to random inspections throughout the year by DFPS. Parents are welcome to review the Minimum Standards for School Age and Before or After School Programs here. A copy is also available at all After School sites for parents to review. You may also view a copy of Finale After School's most recent inspection report on-site.
Encore clubs are available to the entire student body. These clubs include a variety of enrichment programs that allow your child to develop his or her own skills with professional instructors. Explore all of our Encore options below.


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Hallucinogen Addiction Treatment
The Phoenix Recovery Center
While hallucinogens are a popular drug due to the hallucinogenic "trips" people can experience under their influence, they also carry a host of dangerous side effects, and many are illegal and addictive.
Though the use of hallucinogens in recent years has been relatively low in the United States compared to in days gone by, hallucinogen abuse and addiction remains a widespread problem. In a 2013 study, more than 229,000 Americans reported having used LSD in the past month, and 33,000 reported using PCP. Salvia, ayahuasca and other hallucinogens have also maintained a popular presence in recent years.
The Phoenix Recovery Center is here to help if you or a loved one is struggling with hallucinogen abuse or addiction. Read on to learn more about the many types of hallucinogens, their side effects, and treatment options, or contact us today to get started on the road to recovery.
What are Hallucinogens?
There are many different types of hallucinogens, both naturally occurring and synthetic, but all have the same general effects on people. Hallucinogens are drugs that alter their users' perception of reality, sometimes by impacting their awareness of what is around them as well as their thoughts and feelings, and other times by causing hallucinations, in which people experience images and sensations that feel real but are not.
Hallucinogens have been used by people for hundreds of years for various purposes, including religious ceremonies, but they are also commonly abused for their hallucinogenic effects. But just what are hallucinogens? A hallucinogen is a chemical substance that can be found in plants and mushrooms but also in liquids, powders, pills, and capsules.
Types of Hallucinogens
According to the National Institute on Drug Abuse (NIDA), these are some common hallucinogens:
DMT — Dimethyltryptamine; a chemical that can be found in Amazonian plants or created in a lab; also known as Dimitri.
Ayahuasca — A tea made from several Amazonian plants that contain DMT; also known as Hoasca, Aya, and Yagé.
LSD — D-lysergic acid diethylamide; a power mood-changing chemical derived from a fungus grown on grains such as rye; also known as Acid, Blotter, Dots, and Yellow Sunshine.
Peyote — Mescaline; derived from a small and spineless cactus, but can also be made synthetically; also known as Buttons, Cactus, and Mesc.
Psilocybin — 4-phosphoryloxy-N,N-dimethyltryptamine; a chemical found in many mushrooms from tropical and subtropical regions of the United States, Mexico, and South America; also known as Little Smoke, Magic Mushrooms, Purple Passion, and Shrooms.
DXM — Dextromethorphan; found in some over-the-counter medicines for colds and coughs; also known as Robo.
Ketamine — Used as an anesthetic for surgery on animals and humans; also known as K, Special K, and Cat Valium.
PCP — Phencyclidine; previously used as a general anesthetic for surgical procedures but no longer is due to its side effects; also known as Angel Dust, Hog, Love Boat, and Peace Pill
Salvia — Salvia divinorum; a plant found in southern Mexico as well as South and Central America; also known as Diviner's Sage, Maria Pastora, Sally-D, and Magic Mint
Hallucinogens Effects and Symptoms
Hallucinogens can disrupt the communication between chemical systems in the brain and spinal cord, according to NIDA. Some affect the serotonin in the brain, which impacts our mood, sensory perception, sleep, hunger, body temperature, muscle control and sexual behavior. Others target glutamate in the brain, which impacts our ability to perceive pain, respond to the environment, feel emotion, learn, and create or access memories.
Hallucinogens effects begin within 20 to 90 minutes after taking a hallucinogenic substance and can last for 6 to 12 hours. They vary depending on what type of hallucinogenic substance is used — DMT effects will differ from the effects of LSD or the effects of Acid, for example — but general short-term hallucinogenic effects include:
More intense feelings and sensory experiences
Changes in how time is perceived by the user
Other short-term effects more specific to different forms of hallucinogens include:
Increased blood pressure, body temperature, or breathing rate
Problems with sleep
Feelings of detachment or relaxation
Uncoordinated movements
Profuse sweating
Long-term effects of hallucinogens may include:
Depression and suicidal thoughts
Persistent psychosis
Signs of Hallucinogens Abuse
Unsure if someone you know is using hallucinogens? According to the U.S. Department of Health and Human Services, you can look to see if these signs of hallucinogens abuse are present in your loved one:
Bizarre and irrational behavior, including paranoia
Detachment from people
Absorption with self or other objects
Are Hallucinogens Addictive?
There hasn't been much research into many of the varieties of hallucinogens, but it is known that some are addictive, such as PCP. Others are not classified as such, such as LSD. Even when hallucinogens are not addictive in the general sense, users may still develop a tolerance to them or to similar drugs, where more of the drug must be taken over time to achieve the same effect as the initial, lower doses.
Hallucinogens Withdrawal Symptoms
Someone who is addicted to hallucinogens may experience hallucinogens withdrawal symptoms including drug cravings, headaches, and sweating, according to DrugAbuse.gov.
What is the Treatment for Hallucinogens Abuse and Addiction and What Does That Look Like at PRC?
The Phoenix Recovery Center is equipped to offer therapy and treatment for hallucinogens abuse and hallucinogens addiction. Our services include an Inpatient Residential Program, Partial Hospitalization Program (PHP) Day Program, Intensive Outpatient Program (IOP), and General Outpatient Program (GOP).
Phoenix Recovery Experience
Patients and their families who choose The Phoenix Recovery Center to receive their hallucinogens treatment for addiction or abuse learn and develop both recovery and disease-management skills. We also help our patients and their families to identify, define, and achieve stability in their pursuit of a meaningful life. Through the tools we provide and their own efforts, patients and their family members can achieve improved emotional and cognitive health and can begin to heal their relationships.
We are excited to answer your questions about hallucinogen addiction treatment and to support you in your healing process as you reclaim the life you desire. Give us a call at (801) 438-3185 to learn more about treatment for hallucinogens abuse.
The Phoenix Recovery Center is driven by this guiding mission statement: "Empowering individuals and families suffering from addiction and mental health disorders to celebrate life through lasting solutions."
Hallucinogen addiction treatment at The Phoenix Recovery Center is a carefully tailored program defined by research. We make every effort to support outcomes that prepare patients and their families to manage their hallucinogens addiction and to reclaim a meaningful life. We equip those we help to overcome hallucinogens abuse with both the knowledge and the applied behaviors they need to continue on a path to success.


Printed books are not sold on this web site. If you want to order a printed paperback book of this title, you may do so at Barnes&Noble or Amazon. Click on the link that you prefer below.
For many women, the call to ministry is particularly challenging. Those of us raised in the Baptist tradition were often taught that God simply doesn't call women-but only men-to the ministry. And yet, the Spirit continues blowing where she will, dancing around both women and men, inviting all to join in service. What is a woman to do when she hears that call? How is she to remain faithful to what she was taught, while remaining faithful to the voice of God?
The Modern Magnificat is an attempt to chronicle the journey of calling. In its pages, you will find the stories of twenty-three Baptist women who heard God's call. These women are from a variety of backgrounds, spanning Baptist life. You will find Southern Baptists, Cooperative Baptists, American Baptists, Missionary Baptists, Alliance of Baptists, and others. There are women who are committed to being life-long Baptists. There are women who find their identity in the Baptist church, but have found places of service among the Disciples of Christ, United Methodists, and Mennonites. There are women who are not sure if they will be able to remain Baptist.
The mark of a disciple of Jesus is a willingness to go wherever you are called. These stories of women answering God's call to ministry powerfully personalize theology debates that detail what women can and cannot do. The one thing a disciple, regardless of gender, dare not do is ignore the call of God.
Rev. Jennifer Harris Dault has offered us a gift in sharing the sacred stories of women called to ministry. From dramatic clarion calls to insistent and incessant yearnings of the soul, these poignant stories give witness to the diverse and distinct ways in which God calls and the amazing array of gifts God pours out on women from all walks of life. After reading these stories no argument is needed or defense required for women called to ministry. It is abundantly clear that God calls women to ministry and God gifts women for ministerial leadership.
—Patricia Hernandez, Director of American Baptist Women in Ministry and Transition Ministries for ABCUSA, Baptist Women in Ministry (American Baptist Churches USA).
In the 21st century, when we take for granted the integration of women in all areas of our common life, it is vital to hear the stories of women called into ministry. Harris Dault has given us a window into the particular challenges that Baptist women face. These stories reveal the power of call, the passion to follow Jesus, and the willingness to continually break new ground in often hard and rocky soil. These stories are a must read for women and men who want to transform the church into a more welcoming and affirming place for those called into its service.
Jennifer Harris Dault has assembled a collection of eye-opening, life-changing, thought-provoking stories of women called to ministry. These are convincing testimonies that answering God affirmatively, following Jesus faithfully, and yielding to the Spirit completely do not guarantee easy paths. Their journeys include steep hills, deep valleys, sharp curves, and rough terrain, but the collective witness of these pages should persuade readers that ministry is a noble call that is worth the effort. Priesthood of ALL Believers is a gift of honest and transparent narratives that stir emotions and invite respect for the wisdom, grace, and grit they portray.
Life is lived and remembered in stories. Stories have formed our personalities, influenced our decisions, and shaped our faith. For ministers, calling cannot be understood apart from the greater story and the individual stories. As a lover of stories, I am grateful to Jennifer Harris Dault for collecting call stories from twenty-two Baptist women ministers, who write beautifully of their formation as Christians, their experience of calling, and their adventures in living out that calling. They are stories of struggle, disbelief, pain, and seemingly insurmountable obstacles, but they are also stories of joy and delight in the hearing and following of God's call. Each story was a reminder for me that God does indeed call, gift, and grace Baptist women for the work of ministry.
Jennifer Harris Dault is a church administrator, freelance writer, and supply preacher living in St. Louis, Missouri. She lives with her husband, Allyn, and their two cats, Sassy and Cleo. She currently enjoys expressing her faith as a Baptist working in a Methodist church while worshipping with a Mennonite congregation. Read more from Jennifer at her blog.


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I am running the leatest EAP and 94.273 and in both, I have the same problem when integrating GIT. I first add the remote repo, all is imported and looks well. But then when doing a ctrl+K, I always get the "No changes detected" message. And all files seem to be "unadded" (the ones from the repo!). Also, the git push/pull dialogs are no where available. Instead "Subversion, add..."
control system is selected for the directory.
the "No changes detected" message. And all files seem to be "unadded"
where available. Instead "Subversion, add..."