This list of dental schools in the United Kingdom includes all eighteen Dental Schools or Schools of Medicine and Dentistry in the United Kingdom which are recognised by the General Dental Council and lead to a dental degree of a British university.
University dental schools in the UK offer postgraduate programmes in a variety of dental subjects. The postgraduate courses offered may be: Diplomas, Masters or Doctorates.
At Dentale we are training dentists in the provision of dental implants. This is a continuous ongoing process taking dentists from their first implant all the way up to the most complex procedures.
Welcome to LonDEC. Unrivalled Dental Education Centre in London, we offer world class dental courses for every member of the dental team in the heart of central London.
Entry requirements and training (dentistry) Hospital dental services; Real-life story … Becoming a dentist involves at least five years' study at dental school, … The GDC sets the standards for UK dental education at undergraduate and postgraduate level.
The City of London Dental School. The City of London Dental School is an independent dental school which provides degree courses in dentistry. The school is licensed as a Higher Education Institution and regulated by the National Commission for Further and Higher Education NCFHE (Malta).
The Faculty of Dental Surgery (FDS) is a professional body committed to enabling dental surgeons to achieve and maintain excellence in practice and patient care.
Dental Assisting Distance Learning Course – Certificate / Diploma / Advanced Diploma Levels. This distance learning Dental Assisting course provides all the training required to become a reliable and qualified dental assistant.
Dental technology programmes and qualifications Dental technology … School of Dental Technology. … Higher Education Diploma in Dental Technology. This programme has been provisionally accepted by the GDC Registrar.
Welcome to Dental Training Schools. Now is a great time to join one of the most sought after, and fastest growing careers! Dental assistant and dental hygienist Jobs are currently growing at over 30%, which is much faster than the average for all occupations.
In the table below are details of qualifications leading to registration with the GDC as a dental technician. You will also find the details of the schools which offer programmes in these qualifications.
The Dental Care website is the number one resource for all dentists and dental professionals. We provide a variety of articles on dental and oral care.
Developing high calibre dental professionals. We are one of the top dental schools in the UK providing a modern and safe learning environment for students to develop knowledge and clinical skills to excel at a career in dentistry.
Dental CPD Courses with LonDEC. An exceptional provider of postgraduate and CPD dental training courses situated in the heart of London. Call Today.
The Leicester Dental Teaching Academy provides the most exciting developments in dental education in the UK with a mission to develop highly qualified dentists for the international market.
Dental Schools and Programs You can find information about dental schools and programs on The Commission on Dental Accreditation (CODA) website.
Why choose this course? The Diploma in Implant Dentistry, run by the Faculty of General Dental Practice (UK), teaches implant primary dental care to general dental practitioners.
Dental Nursing Courses London: SLA has the City and Guilds Level 3 Diploma Dental Nurse Course that would suit anyone who would like to pursue a career in dental nursing.
Home; UK Courses; UK Courses Dental Nurse Courses in the UK Courses for Dental Nurses are available across the UK. Click on an area below for details of the main course providers in that location.
Not currently working or training; Still unsure; A teacher or careers adviser; Share on Twitter; … Watch our video or read our FAQs to learn how to use the course finder . … //www.bangor.ac.uk/courses/undergraduate/B760-Mental-Health-Nursing. BN (Hons) Learning Disabilities Nursing.
Free Dental Treatment. Our waiting lists for free dental treatment are currently open. Thank you for your interest in free dental treatment at the Dental Hospital.
Top Dental School in the UK for research quality (REF 2014). Study With Us. 3rd in the UK for Dentistry (2017 Complete University Guide) Athena SWAN. Equality, Diversity, inclusion: Creating a great place to work. Follow us on Twitter Subscribe on YouTube.
Programme Description. Postgraduate Medical & Dental Education undertakes and supports a range of educational research and evaluation activity in the healthcare professions, particularly medicine and dentistry.
Become an apprentice or a qualified dental nurse by taking on one of our courses. Post qualification courses are currently on offer for £580-exam fee included.


Read some of our previous clients' reviews on Tripadvisor and find out what to expect on our trips!
We are always focused on giving you the best service and make your kite experience with us unforgettable!
I joined the kite expedition to Cabo de la Vela and learned kitesurfing with Jonathan and Lisa. It was a trip of 5 days and I completed the kite lessons and finished riding a few meters. They were taking care of everything on the side: transfer, accommodation, food, some extra activities. All in all, we had a great relaxed time with a nice group of people!
After that I was pretty much hooked to this awesome sport and did two more short day trips with them to two different spots close to Riohacha. We did a flamingo observation and I was able to take a few more hours of lessons to practise my kiting skills.
I can completely recommend Praia kitesurf: great service, great people and one of the best experiences during my vacation in Colombia!
Firstly the setup was pretty straight forward and easy. Lisa was very responsive and even picked us up directly and translated for our first breakfast :) what followed was one week of outstanding kite surfing and superb activities. due to the fact that you are traveling while kite surfing its really a unique thing. normally you are stuck in one place and kite the same spot for days but like this you get to experience a vast strip of Colombias diverse country side while also surfing super nice beaches. Lisa and Johnathan cared for us more than i could have wished for. great food, good people, good surf material and lots and lots of fun.
I joined a kitesurf expedition in Cabo De La Vela with a group of 4 people. We had time to take lessons, sleep, eat, relax and have fun for the entire week. The mobile school is amazing and the equipment is brand new and top-notch. Lisa and Jhonatan are two very knowledgeable and super patient instructors. They are IKO certified, they speak English, Spanish and German and they truly understand the essence of teaching. They will take you there, no matter how often you make a mistake or have to repeat an exercise: they will be at your side until you learn and feel confident.
Do not think twice, this is the best school to learn kitesurfing.


Sea Bass with Salsa Fresca Sauce recipe today with the daily updated recipe from NYC Chef Dr. Delicious recipe collections - an Italian, French, or Haute Cuisine Recipe Collection. Recipes include Seafood, Shrimp, Salmon, Steaks, Swordfish, Beef, Chops, Veal, Pork, Filet, Sole, Chicken, Rice & Pasta. New York City restaurant chef and editor review these daily recipes. New York, New York - Restaurant capital of the world.
"Sea Bass with Salsa Fresca Sauce"
Sauce: Combine the chopped tomatoes, sugar, salt and pepper in a medium bowl. Stir and let rest for 30 minutes for the flavors to combine.
Sea Bass: Preheat the oven to 450 degrees. Sprinkle the fish with the salt and pepper. In an ovenproof nonstick sauté pan set on medium high heat, cook the olive oil until sizzling, about 2 minutes. Add the fish, reduce the heat to medium and cook for 2 minutes on both sides, well browned. Place the sauté pan in the preheated oven and cook for 8 to 10 minutes. While the fish is cooking in the oven, finish the sauce by whisking together the 1/2 cup olive oil and the vinegar until well mixed and slightly thickened. Stir in the chopped tomato mixture, garlic and basil. To serve, arrange the fillets on a dish, top with the sauce and garnish with parsley.


text:
Frequency and Spectrum of Induced Viable Macromutations in Chickpea (Cicer arietinum L.) Cultivar 'Vishwas'
Studies on Haemolytic Properties of Puffer Fishes from South East Coast of India
Effect of Gamma Rays in Induced Morphological Mutants on M2 Generation of Chilli (Capsicum annuum L.) Var K1
Global Scenario of Acrocarpus fraxinifolius Wight & Arn. - A Future Tree of Agro Forestry
Screening of Different Leaf Extracts of Cassia fistula Linn for Investigation of Hypolipidemic Activity in Two Different Rat Models
Influence of GA3 and IAA and their Frequency of Application on Seed Germination and Seedling Quality Characters
ILNS > ILNS Volume 30 > Effect of Gamma Rays in Induced Morphological...
The present study was carried out to induce morphological mutation in chilli (Capsicum annuum L.) var k1. The seeds were subjected to different treatment levels of gamma rays are 20, 30, 40, 50, 60 and 70Kr along with control. The treated and untreated seeds were raised in a randomized block design to observe the different morphological characters in M2 generation. Several unique and interesting mutants were isolated in this investigation, these independent mutants have differ from control, the most distinct mutants included tall, dwarf, bushy, flower, sterile and pod mutant, was observed in M2 generation.
https://doi.org/10.18052/www.scipress.com/ILNS.30.19
L. Mullainathan and T. Aruldoss, "Effect of Gamma Rays in Induced Morphological Mutants on M2 Generation of Chilli (Capsicum annuum L.) Var K1", International Letters of Natural Sciences, Vol. 30, pp. 19-24, 2015
L. Mullainathan, T. Aruldoss
Chilli, Kr Mutant, Physical Mutagens
Alcantara T. P., Bosland P. W., Smith D. W., J. Hered. 87 (1996) 239-241.
Blixt S. Agr. Hort. Genetica 30 (1972) 1-293.
Chary S. N., Bhalla J. K., Indian J. Bot. 11 (1988) 169-176.
De Haro A., Del Rio M., JAOCS 75 (1998) 281-283.
Konzak C. F., Nilan R. A., Kleinhofs A. (1977).
Leandro P.E., Martin T.M., Jose J.U., Nature (1990) 263-265.
Minocha J.L., Arnason T.J. (1962). Mutagenic effectiveness of Ethyl Methane Sulphonate in barley nature, 196, 499.
Marghittu V., Striinte Agricole 3 (1972) 105-109.
Odeigah P.G.C., Osanyinpeju A.O., Myers G.O., J. Genet. Breed. 50 (1996) 171-176.
Gottschalk W. (1987). The genetic basis of variation. In: Improving Vegetatively Propagated Crops. Academic Press Limited, New York, pp.317-334.
Hosmani, M. M. (1993). Chilli crop (Capsicum annuum L. ). L. B. Publishers and Distributors, Bangalore. ( Received 10 November 2014; accepted 21 November 2014 ).

redpajama_set_name: RedPajamaCommonCrawl


The USDA crop report released Wednesday, September 12th showed production numbers higher. The surprise came in the corn yield. USDA reported an estimate of 181.3 bushels per acre, which surpassed the highest pre-report estimate by 1.3 bushels per acre. This would give us a production of 14.827 billion bushels nationwide. On the demand side of the equation, corn demand was increased 125 million bushels. Ending stocks at 1.774 billion bushels and a stocks to use ratio of 12%, are both down from a year ago. In addition, global ending stocks are down 37.12 million metric tons, which equates to 1.461 billion bushels. World stocks outside of China and the United States are tight. This equates to only a 37 day supply. China's stocks are rapidly being depleted.
USDA showed soybean production being estimated at 52.8 bu per acre, which was in line with expectations. With the ongoing trade war, there remains limited markets to access for soybeans. Their continues to be no bid for the Pacific Northwest market, keeping pressure on basis levels. The market is discouraging soybean production, which pushes acres from soybeans to corn.


text:
Q: r igraph - find edges connecting seleted nodes I need to highlight selected nodes in a plot, with the full graph as semi-transparent background. In plot, I can easily ifelse vertices that fall inside or outside my list of selected nodes, to differentiate their colors. But I haven't been able to do the same with edges. How do I index the edges that connect my selected nodes?
x <- make_ring(10)
get.edge.ids(x, c(1,2))

get.edge.ids works only if you provide an even number vertices, not if you provide a possibly uneven arbitrary number.
This question here is similar to mine, but not the same.

A: OK, I found a solution. Not sure if it is the most elegant solution, but it works. If you look inside igraph.es objects, names are stored in the form "name1|name2". So you induce a subgraph containing only your selected verticies, you turn it into an edgelist, and then apply a column merge with a "|" collapse, which gives you the desired "name1|name2"-formatted edges. Then you create an edge color attribute for your target edges.
x <- make_ring(10)
V(x)$name <- LETTERS[1:10]
target <- V(x)[1:5]$name
target <- as_edgelist(induced.subgraph(x, target))
target <- apply(target, 1, function(z) paste(z, collapse = "|"))
E(x)$color <- "blue"
E(x)[target]$color <- "red"
plot(x, edge.color = E(x)$color)

A: The E and V functions have numerous iterators and subsetting functions as described a bit here: http://cneurocvs.rmki.kfki.hu/igraph/doc/R/iterators.html
For instance to get all edges that connect to Vertex 1 you can do:
library(igraph)
x <- make_ring(10)
E(x)$color <- "black"
E(x)[adj(1)]$color <- "red"
plot(x)

Update:
If the vertices are not adjacent then you need to first find the path between them.
eids <- all_shortest_paths(x, 1, 4, "all")
E(x)$color <- "black"
E(x)[ eids$res[[1]] %--% eids$res[[1]] ]$color <- "red"
plot(x)

redpajama_set_name: RedPajamaStackExchange


text:
Director of Bands
Jay Davis is beginning his seventeenth year in education, fourth as the Director of Bands at Houston County High School in Warner Robins, Georgia. Prior to his appointment at HCHS, Davis served as the band director at Eagle's Landing Christian Academy, Eagle's Landing Middle School and Lovejoy High School. Davis also was the adjunct professor of trumpet at Georgia College and State University and taught courses in the music education department. He holds degrees from Georgia College and State University and Auburn University, both in Music Education.
As Director of Bands at Houston County High School, he oversees over 300 students daily divided into four concert ensembles, a jazz ensemble, a percussion ensemble, and a dedicated color guard class. The Black and Silver Brigade, HCHS's marching unit, includes two marching bands, serving over 200 students. Bands under his direction have consistently received Superior ratings at adjudicated events throughout the southeast in both the concert and marching areas, including winning Grand Champion honors at the 2017 Sound of Gold Marching Invitational. Additionally, the Houston County High School Band was awarded the Exemplary Performance Award by the Georgia Music Educators Association, one of only two high school programs in the state to receive this award for the 2016-2017 school year. Students under his direction have placed in many honor groups, including the Georgia All State Band, the Governor's Honors Program, and the Atlanta Youth Wind Symphony. Jay has worked on the faculty of the GCSU Jazz and Symphonic Music Camps, as well as the staff for the Encore Music Camp and Camp ExtravaBANDza. Jay previously performed with the oldies band, Reunion, and the Symphonic Band Tara Winds, where he was on the Board of Directors. He now performs in the Wellston Winds, and serves as an associate conductor. He currently serves on the GMEA All State committee and will be serving as GMEA District Eleven Chair for 2018-2020. Jay holds or has held memberships in the International Trumpet Guild, Pi Kappa Lambda, GMEA, the National Band Association, and was Province Governor for Phi Mu Alpha Sinfonia, a fraternity for men of music. He has also served on the Board of Directors of the Georgia College Alumni Association.
Jay is married to Dr. Tina Holmes-Davis, Assistant Professor of Music Education at Georgia College, and is the proud father of 13-year-old twins, Emma (an aspiring trombone player) and Jonah (an asping percussionist).
Rob Ingram
Assistant Director of Bands
Mr. Rob Ingram was recently appointed the Assistant Director of Bands at Houston County High School. Before his time at Houston County, he served as the Director of Bands at Mount de Sales Academy in Macon, Ga. While at Mount de Sales he was responsible for all beginning band classes, concert band, and marching band. Mr. Ingram earned his Bachelor's Degree in Music Education with an emphasis in Instrumental Music from Georgia Southern University in 2016. While at Georgia Southern Ingram, was the Drum Major of the Southern Pride Marching Band for two years, lead alto in the Jazz Ensemble for two years, and Principal Saxophone in the Symphonic Wind Ensemble for two years. Mr. Ingram currently plays saxophone in Wellston Winds.
Miguel Castro
Percussion Instructor
Miguel studied music from 1977 to 1983 at the "Conservatorio Nacional de Música" in Santo Domingo, Dominican Republic earning a Master's Degree in Music Performance. After that, he went to New York to study at Drummers Collective International in 1984-85 where he had the opportunity to study with some of the world's leading percussionists including Steve Gadd, Doug Allen, and Frank Malabé.
In 1989, Miguel moved to Germany where he played in numerous Latin American, jazz, pop and chamber groups as well as pursuing an extensive recording career. He did tours throughout Europe with various groups and performers, amongst them the Puerto Rican Salsa star Marvin Santiago. Miguel has been a recording artist with ARC Music record label since 1992 and has produced 17 Compact Discs since then. He has played in various orchestras (Orquesta Sinfónica Nacional of Dominican Republic, Swiss Philharmonic Orchestra, Carol Morgan Operatic Society, Orquesta Sinfónica de Maracaibo), and currently performs with The Macon Symphony Orchestra in Macon, Georgia and the Ocmulgee Symphony Orchestra in the Middle Georgia area.
In 1992, he returned to the U.S. where he has continued as an active performer as well as a teacher of all percussion disciplines. He served as Director of Percussion Studies at Mercer University in Macon for eight years. At the present time, he serves as Director of Percussion Studies and Jazz Band at Middle Georgia College in Cochran, Georgia since the beginning of the Instrumental Music program (established in 1998 by Mr. Louis Foster, Director of Bands). Mr. Castro is also currently the Percussion Coordinator of the Houston County School System. He is regularly in demand as a percussion clinician (Percussive Arts Society International Convention, Georgia Music Educators Association Conference, Georgia Percussive Arts Society Conference, and Southeastern United States Band Clinic), adjudicator, composer, arranger and recording artist, maintaining a busy schedule in and outside of the United States.
Colorguard Specialist
Tara Elderkin
I am a mom of four awesome children and a wife to my amazing husband, Clark. I have degrees in General Business and Business Management, a Master's degree in Educational Technology, and a Specialist Degree in Instructional Technology. I have teaching certifications in twelve different areas including Special Education, secondary Mathematics, and Instructional Technology, and safety certifications in first aid, CPR, and AED.
I am a former band member myself and absolutely love working with the marching band. By day, I am an Interrelated Mathematics teacher at Houston County High School. In the afternoons, evenings, and weekends, I transform into whatever Davis and Ingram need me to be. I am responsible for everything from med forms to attendance to bus rosters to popsicle Thursday. As long as it is possible, wherever the students are, that's where I will be.
Amelia Walker
Amelia Walker, alumni of Houston County High School, I am also the Med Tech of HCHS. Working with adolescents has always been my passion. I have Masters in Psychology. This is a very exciting year for HCHS band and look forward to assisting them with any medical attention and guidance they may need. Go Bears!


text:
from typing import TYPE_CHECKING

if TYPE_CHECKING:
    from typing import Optional

class HeadersMixin(object):
    @property
    def _headers(self):
        # type() -> dict
        return {"api-key": self._credential.key, "Accept": self._ODATA_ACCEPT}

    def _merge_client_headers(self, headers):
        # type(Optional[dict]) -> dict
        if self._aad:
            return headers
        headers = headers or {}
        combined = self._headers
        combined.update(headers)
        return combined

redpajama_set_name: RedPajamaGithub


text:
Paradise Papers: Theresa May Has 'Questions To Answer' Over Lord Ashcroft Donation, Says John McDonnell
Theresa May has "questions to answer" over the tax status of former Tory treasurer Lord Ashcroft, John McDonnell has said.
Leaked documents - dubbed the Paradise Papers - have revealed Lord Ashcroft maintained his non-dom status in Belize despite having been believed to have given it up.
The move, while not illegal, allowed the Tory peer to avoid paying taxes in the UK on his earnings abroad.
Lord Ashcroft, a former deputy chairman of the Conservative Party, fell out with David Cameron. However he donated £500,000 to May's recent general election campaign.
Speaking to Sky News this morning, McDonnell said the prime minister should come clean about what she knew about Lord Ashcroft's status.
"If the identification of Lord Ashcroft, a major Tory party funder, on the list and if the allegations of tax avoidance are true, it means that the prime minister has questions to answer," the Shadow Chancellor said.
"What did she and the Conservative Party know about Ashcroft's tax affairs and what due diligence checks were applied before she agreed to the Conservative Party accepting significant donations from him?"
A spokesman for Lord Ashcroft told The Guardian that the peer had never engaged in in tax evasion, abusive tax avoidance or tax avoidance using artificial structures and "any suggestion or implication that he has will be vigorously challenged".
Challenged by the BBC at the Conservative Party conference over his tax status, Lord Ashcroft simply said "dear, dear, dear".
Labour has called for a full public inquiry into the Paradise Papers leaks, which tie major companies and political figures, including the Queen, to secretive overseas arrangements.
The Waugh Zone Monday November 6, 2017
Ferne McCann Shares Daughter's Unusual Name After Giving Birth A Week Early


Copyright: © 2016 Upadhyay, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Procedural sedation and analgesia is one of the common clinical practices in the emergency department. The level of sedation must be adjusted in such a way that it allows patient to tolerate unpleasant procedures while maintaining normal physiologic reflexes and consciousness and able to understand and respond to verbal or light tactile stimulus. Although drugs used for procedural sedation has wide margin of safety but inappropriate monitoring or dosing may cause serious adverse event. Procedural sedation in emergency department is not without risk. Proper monitoring; provision of readily available access to resuscitation facility and continuous presence of trained staffs capable for airway management and providing advanced life support measure contributes reduction in adverse outcome. Pre-procedural evaluation is done to screen for suitability for procedural sedation and assesses the risk factors. Patients with full stomach, difficult airway or significant medical illness requiring more than mild sedation, alternative to procedural sedation should be considered. Clinician performing procedural sedation should have through knowledge of action, dose, side effects and antidote of commonly used sedative analgesics. Newer and innovative techniques have been evolved recently including transmucosal, Tran's nasal, inhalation anaesthetic, patient controlled sedation, target controlled sedation. All patients after procedural sedation should be monitored in a designated recovery area and should not be discharged until they meet all the discharge criteria and while sending home, proper written discharge instruction should be provided to all.
Use of procedural sedation and analgesia is one of the common clinical practice in the emergency department. Effective use of procedural sedation not only alleviate pain and suffering and alloy anxiety for patients during diagnostic or therapeutic procedure, but also enhances the performance of these procedures. Procedural sedation is also described as conscious sedation. A stage of sedation is a continuum from minimal or mild sedation, moderate sedation, and deep sedation to fully unconsciousness which is consistent with general anaesthesia where all protective reflexes get lost [1-3]. The likelihood of adverse events increases with increasing the depth of sedation.
Procedural sedation is defined as "a technique in which the use of a drug or drugs produce a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the procedure." The drugs and techniques used to provide procedural sedation should carry a margin of safety wide enough to render loss of consciousness unlikely [3-6]. Conscious sedation is popular and widely use term, but it is a misused or vague term as the level of sedation at per definition of conscious sedation by American Association of physician (AAP) in 1985 is insufficient for most painful procedures, specially in children .
The level of sedation must be adjusted in such a way that it allows patient to tolerate unpleasant procedures while maintaining normal physiologic reflexes and consciousness and able to understand and respond to verbal or light tactile stimulus. Current definition of moderate to deep sedation is considered as gray zone. Procedural sedation in uncooperative children is another aspect and are often not covered by standard definition and guidelines. One of the important aspects for certain procedure is absolute immobility and for such children the key to success is inducing sleep. The terms sleep sedation or safe sleep was evolved and defined as the patient is not easily roused with a safety margin wide enough to render the loss of airway and breathing reflexes unlikely . Although drugs used for procedural sedation has wide margin of safety, but inappropriate monitoring or dosing may cause serious adverse event. Goals of procedural sedation and analgesia are to minimize physical pain and discomfort, maintain patient safety and welfare, control anxiety, minimize psychological trauma and to provide maximum amnesia.
The American Society of Anesthesiologists (ASA) describes two broad class of sedation; non-dissociative and dissociative; the nondissociative is sub classified into four levels based on depth of sedation-from minimal sedation to general anaesthesia-in addition to dissociative sedation . In practice, prolonged deep sedation or general anaesthesia is rarely used in the emergency department in the absence of a clinician with appropriate training in anaesthesia.
Procedural sedation and analgesia: Technique of administering sedative or dissociative agents with or without any analgesic to induce an altered state of consciousness to allow the patient to tolerate unpleasant or painful procedures while preserving cardio-respiratory functions .
Minimal or mild sedation and analgesia: Essentially mild anxiolysis or pain control with near-baseline level of alertness. Patients respond normally to verbal commands, although cognitive and coordination might be impaired. Example of appropriate use: changing burns dressings.
Moderate sedation and analgesia: It is deeper level of sedation than mild sedation; patients are sleepy, but easily aroused by verbal or tactile stimuli. Although their airway and respiration and cardiovascular functions are usually maintained, these may be suppressed with deeper levels of sedation (which is a continuum). Moderate level sedation exhibit slurred speech, delayed response to verbal stimuli and may have amnesia as well. Example of appropriate use: direct current cardioversion.
Deep sedation and analgesia: patients require painful or repeated stimuli to evoke a purposeful response. Airway or ventilator support (or both) may be needed. Cardiovascular function is usually maintained, but not assured. Example of appropriate use: major joint reduction (dislocated shoulder reduction).
General anaesthesia: patient has no purposeful response to even repeated painful stimuli. Airway and ventilator support is usually required. Cardiovascular function may also be impaired. Not appropriate for general use in the emergency department except during emergency intubation.
Dissociative sedation: Dissociative sedation is described as a trancelike cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respiration, and cardiopulmonary stability. Ketamine is the commonly used agent to induce dissociative state. Example of appropriate use: fracture reduction (distal radius fractures in young adults).
Unlike operative room or other area; the emergency department is a unique environment where patients arrive any time on unscheduled basis and often with challenging medical problems which may require prompt interventions to stabilization or prevent further deterioration.
Major unique challenges with anaesthesia outside operative room include those related to patient, procedure and environment. Physician unfamiliar with the anaesthesia outside operative room tends to underestimate the fact that patients undergoing procedure that require newer and advanced technological equipment are at higher risk . Unfamiliar location, inadequate monitoring, insufficient or untrained staff and non-availability of emergency resuscitation equipment or medication in emergency situations places both emergency physician and patients at risk. Clinician involved in procedural sedation must understand the nature of the procedure, invasiveness, positioning and duration for the procedure and will formulate the plan in advance in liaise with proceduralist including contingencies for emergencies and adverse outcomes. Nursing and technical staff involve in procedural sedation must be trained to assist or carry out immediate cardiopulmonary resuscitation (Table 1).
-Adequate monitoring equipment to allow adherence to the "Standards for Basic Anesthetic Monitoring"
American Society of Anesthesiology (ASA) has provided minimal guidelines for anesthesia in the non-operating room to improve the quality of patient care .
Patients undergoing procedural sedation in emergency room are thought to be at increased risk of aspiration as most patients will not be properly fasted state and their stomach are often full. Aspiration of gastric content above a critical volume and acidity can cause severe respiratory and systemic consequences  Although American Society of Anaesthesiologist (ASA) has given a clear guideline for preprocedural fasting for patient undergoing elective procedure under sedation or general anaesthesia. ASA recommends minimum fasting of two hours after drinking clear fluid, four hrs after breast milk and six hrs after formula feed or solid  Implementation of these guideline in emergency department is not always practically possible. Most patients don't meet the fasting requirement and most of the procedure are of emergent nature and cannot be delayed. The importance of fasting in emergency room for preventing aspiration during procedural sedation remains unclear [20-24].
So far, we don't have clear evidence to show a relationship among fasting time, gastric volume and acidity, depth of sedation and likelihood of aspiration. Clinically, it is very rare to have significant aspiration of gastric content during emergency procedural sedation . Endotracheal intubation may not protect from aspiration, aspiration can occur, despite the presence of an endotracheal tube. After reviewing the available literature, the American College of Emergency Physician policy statement of procedural sedation analgesia states "Recent food intake is not a contraindication for administering procedural sedation and analgesia, but should be considered in choosing the timing and target of sedation" . To reduce the risk of aspiration, following approach may be appropriate for emergency procedural sedation.
• It is always better to carefully consider the risks and benefit of performing a procedure in emergency. It is reasonable to wait if the patient is full stomach and the procedure is not a true emergency especially when a potential risks of aspiration or a potentially difficult airway exist [23,25] (bowel obstruction, extreme of age, depressed mental state, trauma).
• Avoiding deeper level of sedation: although, no evidence exist that deeper level increase the risk of aspiration. However, light level of sedation permit patient to maintain protective airway reflexes .
• No role of pre-procedural antacid or motility agents in reducing aspiration risk in emergency procedural sedation .
Patients undergoing deeper level of sedation where verbal contact might be lost; it is better to adhere to fasting guideline of ASA (2 hrs for clear fluid, 4 hrs for breast milk and 6 hours for formula or solid .
Valid consent is an absolute requirement for all patients requiring sedation. The rules and regulations varies around the world; for Informed consent is a function of the Legal Process of that Particular Sovereign Nation. Regardless of Geography, Sedation, and all possible adverse effects of Sedation, must be completely explained in a manner comprehensible to the patient, or in the case of a Minor – his Legal Guardians/Parents.
The choice of personnel chosen to administer sedation is varied and maybe administered safely by other clinicians, including emergency and critical care physicians and nurse specialists . Whoever is performing the procedural sedation; he/she should have in-depth knowledge of the relevant medication (action, side-effect, reversal) and should be well versed in advanced cardiovascular life support (ACLS) including skill of airway managements. Number of personnel needed for any procedural sedation may very according to the patient and the procedure. Minimum of one clinician performing procedure and one nurse administering sedative analgesic and monitoring and recording patient's clinical status and vital signs should be followed in any procedure . Serious adverse event can still occur after any procedural sedation, according to ASA guideline there must be someone with advanced life support skill to be immediately available (within five minutes) whenever need arises . It remains controversial whether a separate clinician who is skilled in deeper sedation and airway management should also be present apart from the clinician performing the procedure in the emergency room [3,27]. Hogan et al. in a prospective observational study involving procedural sedation performed by single emergency physician (EP) had comparably similar high success rate with low complications when compared with procedural sedation performed by EP along with a nursing staff  each hospital should have their policy guideline and the accreditation for sedation practice within the emergency department. The director of the emergency department responsibility to provide the approval status to non-specialist medical staff to perform the procedural sedation. The sedation accreditation is suggested for all clinician engaged in procedural sedation in emergency department.
Basic monitoring should be of same standard basic monitoring as in operating room. Close claims in cases with adverse events during procedural sedation frequently judged as substandard monitoring . The Location of the Sedation must be checked and made familiar by the sedationist before the case. Suction, airway equipment of appropriate size, provision for positive pressure ventilation device, intravenous equipment, pharmacological antagonist and basic resuscitation medication should always be available before proceeding with any level of sedation . Staff must be trained to observe the vital signs of the Sedated patient and react in an appropriate way for Sedation. Continually evaluating and monitoring respiratory and circulatory requirements prior to, during, and following the procedure is essential. Continuous electrocardiography and oceanography monitoring should be done in cases involving moderate to deep level of sedation, during prolonged procedure or in high risk patients. Close observation for patient appearance, airway patency and response to stimuli (verbal, tactile) are essential part of monitoring during procedural sedation [2,9,29]. Supplemental low-level of oxygen does not reliably prevent hypoxia, may in fact delay the detection of hypoventilation during procedural sedation in patients without capnography monitoring [30-34] supplemental oxygen (high flow) should be given to patients at higher risk or deeper level of sedation or procedure lasting longer duration (Table 2).
Table 2: Monitors and equipment for non-operating room anesthesia.
There are ranges of techniques available for procedural sedation. Whatever the technique is used, the selection of technique must be appropriate for the individual patient and procedure and not chosen simply for operator or sedationist convenience or at the insistence of a third party. Use of sedative medication should not negate the need for good communication and behavioral management. Adopting the principle of minimal intervention, the simplest and safest technique that is likely to be effective based on patient and clinical needs to be used.
Titration of sedative medication is very important in term of safety and effectiveness. Both over-sedation and under sedation have adverse effect on the patient and delivery of the effective treatment. As a general role single drugs are easy to titrate, combining multiple drugs may produce synergistic effects, have different timing for onset and peak effects and sometime unpredictable and difficult to titrate rendering safety margin narrowed, increasing the likelihood of overdose and cardio-respiratory depression. Another important issue is avoiding very strong sedative drugs with narrow therapeutic indices and reduced margin of safety potentially increasing the likelihood of adverse events. While sedating a patient, care must be taken when combining intravenous medications which might lead to pharmaceutical synergy, with enhanced clinical effects, and consequent narrower margins of safety. In all cases, intravenous sedation is only to be administered by experienced practitioners in justifiable documented cases in a safe approved setting, using routine ASA monitors in all cases, in a facility fully equipped with backup safety measures.
Nitrous Oxide is the oldest inhalation agent used to sedate Dental Cases, labour analgesia and many other surgical procedures. It is odorless, tasteless, ultra short acting (near immediate onset) gas with moderate analgesic, anxiolytic and sedative properties. When combined with Oxygen, Nitrous Oxide provides excellent analgesia, anxiolysis, and light anesthesia. It is commonly delivered in an appropriate nasal mask in Oxygen at concentrations of 40%-70% . It is well tolerated by all age groups, main disadvantages tolerance developed very fast, room where it is used must be well-ventilated with a scavenging system to prevent exposure to others, it is not a very strong analgesic for more painful procedure like closed reduction of fractures. It is incapable of producing deep sedation or general anaesthesia unless combined with other inhalation/intravenous sedative agent. As with of intravenous sedative agents, nitrous oxide should be administered only with standard protocol, the delivery device must employ specific safety features such as prevention of hypoxic mixture and use of pulse oximetry [35-37].
Various drugs available to provide procedural sedation depending on the invasiveness, duration of procedure, facilities for monitoring and resuscitation and expertise of the personnel involved in the sedation process. The greatest threat to the safety of intravenous sedation is airway compromise, loss of airway reflexes and risk of aspiration particularly in emergency procedure and haemodynamic instability. To reduced the risk of cardio-respiratory compromise it is very essential to identify high-risk patient, appropriate selection of medications, adherence to dosing recommendation, appropriate intraprocedural monitoring and prompt intervention when adverse effects are recognized . Commonly used IV sedation either alone or combination of other IV sedative/analgesic are described as below.
Benzodizepines provided number of favorable effects such as anxiolysis, amnesia, sedation and anti convulsive effects. BZD binds to receptor sites in the Gamma Amino Butyric Acid (GABA) system, which facilitate the binding of GABA to its receptor potentiates GABAmediated chloride influx and resulting GABA-nergic actions. The BZD can have adverse effects on respiratory and haemodynamic function. Midazolam is commonly used BZD because of faster onset, less pain on injection, water soluble, more reliable amnesia and shorter duration of action. As BZD lack any analgesic action, it is often combined with opioid, generally fentanyl which resembled in pharmacokinetic profile (rapid onset, duration and offset). BZD has good anxiolysis and amnestic action, but no analgesic action. It can be used as sole agent for mild sedation or combined with opioid or other agents for moderate to deep sedation. It has onset time of 2-5 min after intravenous administration with duration ranging from 30 to 60 minutes. Typical adult dosage of midazolam is 0.02-0.1 mg/kg IV initially; if further sedation is required, may repeat with 25% of initial dose after 3-5 min; not to exceed 2.5 mg/dose (1.5 mg for elderly) and 5 mg total cumulative dose (3.5 mg for elderly) Of note, concomitant use of fentanyl and midazolam have synergistic action and reduces the requirement of each other. Midazolam can be administered by various route including oral, nasal, buccal, transmucosal, intramuscular and intravenous ones [18,36,38].
It is a potent intravenous anaesthetic agent because of its unique pharmacologic profile of rapid onset, reliable sedation, rapid recovery and lack off active metabolite has accounted for its popularity in the arena of procedural sedation. Often used in sub-anaesthetic dosage to provide procedural sedation in various procedures outside the operative room. There is no analgesic action of propofol and is associated with number of side-effects such as pain on injection, rapid attainment and overshoot of depth of sedation than intended. Onset of action is very rapid with peak effects at 90-120 sec with a duration of action range from 5-10 min depending on the dose. Typical dosage 0.5-1 mg/kg IV loading dose; may repeat by 0.5-1 mg/kg increments 3-5 min. Main drawback: It causes hypotension (due to myocardial depression) and respiratory depression. It should be avoided in patients with severe medical problem where there is risk of hypotension that can produce serious complication (sepsis, hypovolemia, cardiac dysfunction). For moderate to deep level of sedation, it is combined with either short acting opioid or with ketamine [39-46].
Ketamine causes profound analgesia with dissociative and amnestic action. It has strong analgesic action even at sub-anaesthetic dosage and with this dose it does not impair upper airway reflexes and thus allowing patient to breathe spontaneously and maintain the protective reflexes. However, though the reflexes may remain intact, but cannot be assumed to be protective . Ketamine has dosed related sideeffects notably increased muscle tone, may cause rigidity, increase in blood pressure and may results in a dissociative state and patient may not be able to speak or respond purposefully to verbal commands. With increasing doses it frequently causes emergence delirium described as vivid imagery, hallucinations, confusion, excitement, irrational behavior, etc. which may last from 1-3 hours. Reported sideeffects of ketamine include tachycardia, hypertension, laryngospasm, emergence delirium, hyper salivation, increased in intraocular, intragastric and intracranial pressure. Excessive salivation can be avoided by using antisialogogue. Avoid stimulation of oropharynx with suction device or other instruments in patients receiving ketamine as excessive stimulation of oropharynx can trigger laryngospasm. Dosage of ketamine for procedural sedation and analgesia: IV 1-2 mg/kg loading dose followed by 0.25-1 mg/kg IV 10-15 min; administer slowly, not to exceed 0.5 mg/kg/min. Intramuscular: 2-5 mg/kg/dose. Oral: 6-10 mg/kg/dose per oral (PO) mixed in cola or other beverage 30 min before procedure. Incidences of delirium and other side effects can be minimized by limiting the dose of ketamine or using it in conjunctions with other sedative hypnotic. Commonly used combination medications with ketamine are midazolam, propofol and dexmedetomidine [46-51].
Etomidate is an imidazole, ultra short acting sedative with minimal cardiac depressant is one of the commonly used medication for emergency procedural sedation because of cardiac stability for procedural sedation it is given IV at dose 0.1 mg-0.15 mg/kg over 30-60 sec and can be repeated after 3-5 min. Onset of action is less than 30 sec and duration of effect 5-15 min [52-54]. It has no analgesic action and require co administration of opioid, common side-effects include; myoclonus and pain on injection, respiratory depression, nausea and vomiting and lowering of seizure threshold. Main drawback of etomidate is that it causes adrenal suppression, although no clinical significance unless repeated dosed or used for prolonged period [55-57].
Opoids mediate analgesics and dose-dependent sedation by acting on both Mu and Kappa opioid receptors. However, the degree of sedation using opioid as sole agent is less intense and unpredictable than that of other sedative-hypnotic. Moreover, high dose opioid are associated with respiratory depression and can occur with any opioid, which is dose-dependent and related to the potency of the opioid chosen  In addition sedation and respiratory depression, another respiratory effects is chest wall rigidity, which is more common with newer synthetic opioid specially when administered in rapidly in large doses and perhaps more common in younger patients [59,60]. Longer acting opioid such as morphine, pethidine are certainly not the agent of choice for procedural sedation because of slower onset and longer duration of action. Shorter acting opioid like fentanyl, alfentanyl sufentanil are often used as analgesic component along with other sedative agent for painful procedural sedation. When used with other sedative agent it has synergistic action and can cause sedation, respiratory depression or hypotension. Unlike the analgesic effects of opioid which follows a fairly consistent dose-response, the sedation and other side-effects do not always follow this pattern and higher doses invariably lead to unpleasant side-effects like as nausea and vomiting .
Fentanyl: Rapid onset of action, 75-125 times potent than morphine, given at dose of 0.5-1 mcg/kg slow IV push (over 1-2 min); may repeat every two minutes until appropriate level of sedation and analgesia is attained. It is frequently used in combination with other sedative mostly midazolam, propofol .
Alfentanil: Alfentanil can be used as sole agent or in combination with other sedative for painful procedural sedation. Can be given at dose of 2.5-5 mg/kg and can be repeated every 3-5 min. Higher doses of alfentanil may be associated with minor respiratory complications requiring interventions .
Combination of midazolam and fentanyl is one of the commonly used medication for emergency procedural sedation. Midazolam alone has very minimal risk of significant respiratory depression, when combined with fentanyl, it can cause hypoventilation, respiratory obstruction needing interventions. Midazolam is relatively slower acting and longer duration than fentanyl, so to get maximum synergism, midazolam be given first and then fentanyl titrated carefully thereafter. Regardless of drug order, clinician must titrate these medication very carefully [3,36,63].
Combination of ketamine and propofol is often called ketofol is a potentially alternative for procedural sedation, they are mostly combined together in same single syringe and are physically compatible for one hour at 23 degrees C . A number of studies have demonstrated that the varying proportion of combination in ketofol (1:1 to 1:10 by weight) for sedation is safe and effective. The combination of the two agents appear to reduce side-effects of each medication used alone, and allows for a rapid recovery time [51,52,64-67]. The optimal ratio of ketamine to propofol in ketofol has not been defined yet. Higher ketamine proportion tends to cause more psycho-mimetic effects while higher propofol may cause more cardiacrespiratory depression. Coulter et al. conducted a dose simulation study using 1:1 to 1:10 ketamine to propofol ratio combination for procedural sedation in paediatric and young adults (2-20 yrs). A ketamine-to-propofol ratio of 1:3 was the best combination for intermittent dosing. Ratio greater than 1:3 resulted delayed recovery. They suggested ketamine to propofol of 1:3 for boluses during short procedures (5-20 min) and 1:4 ratio for short infusion as an alternative to intermittent boluses . Many studies to date failed to show that use of ketofol is more effective and safer than use of either agent (propofol or ketamine) alone for procedural sedation in adults [52,68-70].
Dexmedetomidine is a selective alpha-2 agnosit and has anxiolytic, sedative, analgesic and sympatholytic and reduces anaesthetic requirements . It has been used for procedural sedation in both paediatric and adult patients. It is a sedative with no or minimal respiratory depression, antisialogogue, does not cause tachycardia or hypertension, easily arousable with clear mind [72-74]. Limited data on adult population undergoing procedural sedation with dexmedetomidine has shown it to safe and effective with sufficient analgesia, but limited amnesia and prolonged recovery time [75-78]. Although generally effective for sedation for noninvasive and short procedure, dexmedetomidine as sole agent has not been uniformly successful for invasive procedures. It is slowly losing the popularity as sole agent for procedural sedation due to its slow onset, delayed recovery, minimal analgesia and limited amnesia. However, there is growing interest in combination of dexmedetomidine with ketamine because of anecdotal experience and few series of studies demonstrate the utility and rationale for combination therapy. When used together, dexmedetomidine may limit the tachycardia, hypertension, salivation, and emergence phenomena from ketamine, whereas addition of ketamine speed up the sedation process and may prevent the bradycardia and hypotension that has been reported with dexmedetomidine [79-86]. Various regimens have been reported in the literature, the most common regimen appears to be the use of a bolus dose of both agents, dexmedetomidine (1 μg/kg) and ketamine (1–2 mg/kg), to initiate sedation followed by a dexmedetomidine infusion with supplemental bolus doses of ketamine as needed. Combination of ketamine and dexmedetomidine may be more appropriate for procedural sedation in patients with compromised respiratory or cardiac function. When compared with other agents used for procedural sedation, these two agents have limited effects on ventilatory function when compared with other more commonly used agents. [53,87-89].
Many adjuncts can be used in emergency room to reduce or eliminate the dosage requirement of sedative analgesic. With the advancement in knowledge of ultrasound many peripheral nerve block or regional nerve block can be safely performed in emergency room which obviate the need for moderate to deep sedation . Heamatoma blocks can be used in patients with long bone fracture which also decreased the requirement of strong sedative analgesics for manipulation of fracture .
Patient at risk of hypotension, elderly, multiple co-morbid condition, paediatric and pregnancy are at higher risk for adverse outcome related to procedural sedation; due attention must be paid in drug selection and proper monitoring.
Emergency physician must carefully evaluate the risk and benefit for going ahead with any procedural sedation in patients with increased risk of complications. Patients with septic shock; hypovolemia due to dehydration or volume loss, presence of cardiac disease or some other condition, it is better to use drug which causes less cardiovascular depression; either ketamine, etomidate or short acting opioid be used for procedural sedation.
Patients with known difficult or anticipated difficult airway or where the airway obstruction is anticipated or patients with compromised respiratory function, ketamine is the drug of choice unless contraindicated as it does not cause respiratory depression, increases neck muscle tone to keep airway patent and maintained protective airway reflexes.
The choice and selection of agent for paediatric procedural sedation differ slightly. With development of technology and better pharmacologic profile of modern drugs in new ways with high success. Newer alternate routes has been proposed and investigated such as transmucosal (intranasal, buccal, sublinguial) which has much less discomfort than intravenous route with faster and predictable action than oral sedation. Midazolam is the most frequently used sedative agent in paediatric and can be administered via various route (oral, nasal, rectal, intramuscular, intravenous). It provides excellent anxiolytic and amnesia. It can be safely combined with intranasal fentanyl. Another agent frequently used in paediatric is ketamine which can also be given through various route [91-94]. Propofol and dexmedetomidine is also being increasingly used in paediatric procedural sedation. Dexmedetomidine can also be administered through buccal, intranasal or oral route .
Unlike adult patients, paediatric patients require careful preoperative evaluation and intraoperative monitoring during the procedural sedation as most of the patients in this group requires moderate to deeper level of sedation which may compromise the cardio-respiratory mechanics. Many paediatric patients may actually land up into general anaesthesia; paediatric patients should be prepared and proper fasting guideline to be adhered as if they are going to have full general anaesthesia.
Sedation is generally avoided in pregnant patients, in exceptional cases such patient can be taken up for procedural sedation with proper precaution .
• Gastro prophylaxis: pre-procedural administration of pro-kinetic (metoclopramide) to reduce gastric content and decreased stomach acidity (H2 antagonist, proton pump inhibitor, sodium citrate) may reduce the risk of vomiting and aspiration.
• Pre-procedural hydration and left lateral displacement of uterus-to reduce the risk of hypotension due to aorto caval compression. Fetal monitoring is not required, but should be considered for women in the third trimester.
• Avoid any potential teratogenic drug.
Patients in pain: Any patients in severe pain should be provided with adequate analgesia before proceeding to sedation. Intravenous route is the preferred and most predictable method for providing analgesia in emergency set up. Local factors such as availability of medication, familiarity and clinical experience of the emergency staff will determine the drug choice as will safety, effectiveness and cost factor [5,96].
As sedation is stimulus-dependent, at the end of the procedure as there is no stimulus, patient is likely to become more sedated than during the procedure itself. This can lead to hypoventilation and hypoxia in susceptible patients (extreme of age, patients with cardiorespiratory disease). After the completion procedure, it is important to keep monitoring and recording the vital sign, medications, fluid until the patient responds to verbal or tactile stimulation.
• Vital signs should be within 15% of pre-procedural value.
• Patient should be awake, alert and responds to commands appropriate to age.
• No active bleeding should not be actively vomiting and nausea if any should be mild.
• The patient is accompanied by a responsible adult.
A properly administered procedural sedation not only allows painful procedure to be performed, it increases the performance time and success of any procedure. Sedation level is sub classified into mild, moderate, deep sedation and general anaesthesia. Most emergency procedure requires mild to moderate sedation and analgesia. Whenever deeper level of sedation or GA is intended, it is always safer to involved clinician with more advanced skill in airway and resuscitation (anesthesiologist). All personnel involved in procedural sedation must have knowledge of advanced life support measure and airway management. Adequate equipment, monitoring and resuscitation facility must be there whenever procedural sedation is conducted. Proper patient evaluation; especially the co-morbid medical conditions, fasting status and risk of aspiration and airway evaluation should be meticulously done and recorded.
Adopting the principle of minimal intervention, the simplest and safest technique that is likely to be effective based on patient and clinical needs to be used. Choice of technique or sedation depends patient type, invasiveness and length of the procedure and presence of co-morbid conditions. The ideal drug for procedural sedation should have a rapid onset and short duration of action, maintains hemodynamic stability, and do not cause major side-effects. Several medications are commonly used, but until, no single drug is ideal for all situations All patients after procedural sedation should be monitored in a designated recovery area and should not be discharged until they meet all the discharge criteria and while sending home, proper written discharge instruction should be provided to all.
Furniss SS, Sneyd JR (2015) Safe sedation in modern cardiological practice. Heart 101: 1526-1530.
American Society of Anesthesiologists (2004) Continuum of depth of sedation definition of general anesthesia and levels of sedation/analgesia.
Godwin SA, Caro DA, Wolf SJ, Jagoda AS, Charles R, et al. (2005) Clinical policy: procedural sedation and analgesia in the emergency department. See comment in PubMed Commons below Ann Emerg Med 45: 177-196.
Coulthard P, Craig D, Holden C, Robb ND, Sury M, et al. (2015) Current UK dental sedation practice and the 'National Institute for Health and Care Excellence' (NICE) guideline 112: sedation in children and young people. Br Dent J 218: E14.
Atkinson P, French J, Nice CA (2014) Procedural sedation and analgesia for adults in the emergency department. BMJ 348: g2965.
(1985) Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatr Dent 76: 317-321.
Sury MR, Hatch DJ, Deeley T, Dicks-Mireaux C, Chong WK (1999) Development of a nurse-led sedation service for paediatric magnetic resonance imaging. Lancet 353: 1667-1671.
American society of anesthesiologists task force on sedation and analgesia by non-Anesthesiologists (2002) Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 96: 1004-1017.
Youn AM, Ko YK, Kim YH (2015) Anesthesia and sedation outside of the operating room. Korean J Anesthesiol 68: 323-331.
Miller MA, Levy P, Patel MM (2005) Procedural sedation and analgesia in the emergency department: what are the risks? Emerg Med Clin North Am 23: 551-572.
Robbertze R, Posner KL, Domino KB (2006) Closed claims review of anesthesia for procedures outside the operating room. CurrOpinAnaesthesiol 19: 436-442.
Sacchetti A, Baren J, Carraccio C (2010) Total procedural requirements as indication for emergency department sedation. PediatrEmerg Care 26: 209-211.
The American Society (2010) Statement on non-operating room anesthetizing location Edited by The American Society of Anesthesiologists.
Cheung KW, Watson ML, Field S, Campbell SG (2007) Aspiration pneumonitis requiring intubation after procedural sedation and analgesia: a case report. Ann Emerg Med 49: 462-464.
Sakai T, Planinsic RM, Quinlan JJ, Handley LJ, Kim TY, et al. (2006) The incidence and outcome of perioperative pulmonary aspiration in a university hospital: a 4-year retrospective analysis. AnesthAnalg 103: 941-947.
Cepeda MS, Farrar JT, Baumgarten M, Boston R, Carr DB, et al. (2003) Side effects of opioids during short-term administration: effect of age, gender, and race. ClinPharmacolTher 74: 102-112.
Miner JR, Burton JH (2007) Clinical practice advisory: Emergency department procedural sedation with propofol. Ann Emerg Med 50: 182-187, 187.
Green SM, Krauss B (2002) Pulmonary aspiration risk during emergency department procedural sedation--an examination of the role of fasting and sedation depth. AcadEmerg Med 9: 35-42.
Green SM (2003) Fasting is a consideration--not a necessity--for emergency department procedural sedation and analgesia. Ann Emerg Med 42: 647-650.
Sandhar BK, Goresky GV, Maltby JR, Shaffer EA (1989) Effect of oral liquids and ranitidine on gastric fluid volume and pH in children undergoing outpatient surgery. Anesthesiology 71: 327-330.
Ljungqvist O, Søreide E (2003) Preoperative fasting. Br J Surg 90: 400-406.
Green SM, Roback MG, Miner JR, Burton JH, Krauss B (2007) Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med 49: 454-461.
Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, et al. (2014) Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 63: 247-258.
Bassett KE, Anderson JL, Pribble CG, Guenther E (2003) Propofol for procedural sedation in children in the emergency department. Ann Emerg Med 42: 773-782.
Harrington L (2006) Nurse-administered propofol sedation: a review of current evidence. GastroenterolNurs 29: 371-383.
Hogan K, Sacchetti A, Aman L, Opiela D (2006) The safety of single-physician procedural sedation in the emergency department. Emerg Med J 23: 922-923.
Maher EN, Hansen SF, Heine M, Meers H, Yaster M, et al. (2007) Knowledge of procedural sedation and analgesia of emergency medicine physicians. PediatrEmerg Care 23: 869-876.
Deitch K, Chudnofsky CR, Dominici P (2007) The utility of supplemental oxygen during emergency department procedural sedation and analgesia with midazolam and fentanyl: a randomized, controlled trial. Ann Emerg Med 49:1-8.
Miner JR, Biros MH, Heegaard W, Plummer D (2003) Bispectral electroencephalographic analysis of patients undergoing procedural sedation in the emergency department. AcadEmerg Med 10: 638-643.
Miner JR, Heegaard W, Plummer D (2002) End-tidal carbon dioxide monitoring during procedural sedation. AcadEmerg Med 9: 275-280.
McQuillen KK, Steele DW (2000) Capnography during sedation/analgesia in the pediatric emergency department. PediatrEmerg Care 16: 401-404.
O'Sullivan I, Benger J (2003) Nitrous oxide in emergency medicine. Emerg Med J 20: 214-217.
Bahn EL, Holt KR (2005) Procedural sedation and analgesia: a review and new concepts. Emerg Med Clin North Am 23: 503-517.
Babl FE, Oakley E, Puspitadewi A, Sharwood LN (2008) Limited analgesic efficacy of nitrous oxide for painful procedures in children. Emerg Med J 25: 717-721.
Tobias JD, Leder M (2011) Procedural sedation: A review of sedative agents, monitoring, and management of complications. Saudi J Anaesth 5: 395-410.
Ben-Shlomo I, abd-el-Khalim H, Ezry J, Zohar S, Tverskoy M (1990) Midazolam acts synergistically with fentanyl for induction of anaesthesia. Br J Anaesth 64: 45-47.
Beller JP, Pottecher T, Lugnier A, Mangin P, Otteni JC (1988) Prolonged sedation with propofol in ICU patients: recovery and blood concentration changes during periodic interruptions in infusion. Br J Anaesth 61: 583-588.
Green SM, Krauss B (2003) Propofol in emergency medicine: pushing the sedation frontier. Ann Emerg Med 42: 792-797.
Black E, Campbell SG, Magee K, Zed PJ (2013) Propofol for procedural sedation in the emergency department: a qualitative systematic review. Ann Pharmacother 47: 856-868.
Wan H, Horvath C (1975) Behavior of soluble and immobilized acid phosphatase in hydro-organic media. BiochimBiophysActa 410: 135-144.
Newstead B, Bradburn S, Appelboam A, Reuben A, Harris A, et al. (2013) Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases. Br J Anaesth 111: 651-655.
Andolfatto G, Willman E (2011) A prospective case series of single-syringe ketamine-propofol (Ketofol) for emergency department procedural sedation and analgesia in adults. AcadEmerg Med 18: 237-245.
Green SM, Roback MG, Kennedy RM, Krauss B (2011) Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med 57: 449-461.
Strayer RJ, Nelson LS (2008) Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med 26: 985-1028.
Newton A, Fitton L (2008) Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study. Emerg Med J 25: 498-501.
Sener S, Eken C, Schultz CH, Serinken M, Ozsarac M (2011) Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial. Ann Emerg Med 57: 109-114.
Miner JR, Moore JC, Austad EJ, Plummer D, Hubbard L, et al. (2015) Randomized, double-blinded, clinical trial of propofol, 1:1 propofol/ketamine, and 4:1 propofol/ketamine for deep procedural sedation in the emergency department. Ann Emerg Med 65: 479-488.
Tobias JD (2012) Dexmedetomidine and ketamine: an effective alternative for procedural sedation? PediatrCrit Care Med 13: 423-427.
Miner JR, Danahy M, Moch A, Biros M (2007) Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med 49: 15-22.
Brown TB, Lovato LM, Parker D (2005) Procedural sedation in the acute care setting. AmFam Physician 71: 85-90.
Vinson DR, Bradbury DR (2002) Etomidate for procedural sedation in the emergency medicine. Ann Emerg Med 39: 592-598.
Ruth WJ, Burton JH, Bock AJ (2001) Intravenous etomidate for procedural sedation in emergency department patients. AcadEmerg Med 8: 13-18.
Falk J, Zed PJ (2004) Etomidate for procedural sedation in the emergency department. Ann Pharmacother 38: 1272-1277.
Satoh M, Minami M (1995) Molecular pharmacology of the opioid receptors. PharmacolTher 68: 343-364.
Fahnenstich H, Steffan J, Kau N, Bartmann P (2000) Fentanyl-induced chest wall rigidity and laryngospasm in preterm and term infants. Crit Care Med 28: 836-839.
Müller P, Vogtmann C (2000) Three cases with different presentation of fentanyl-induced muscle rigidity--a rare problem in intensive care of neonates. Am J Perinatol 17: 23-26.
Becker DE (2012) Pharmacodynamic considerations for moderate and deep sedation. AnesthProg 59: 28-42.
Miner JR, Gray R, Delavari P, Patel S, Patel R, et al. (2011) Alfentanil for procedural sedation in the emergency department. Ann Emerg Med 57: 117-121.
Trissel LA, Gilbert DL, Martinez JF (1997) Compatibility of propofol injectable emulsion with selected drugs during simulated Y-site administration. Am J Health Syst Pharm 54: 1287-1292.
Aouad MT, Moussa AR, Dagher CM, Muwakkit SA, Jabbour-Khoury SI, et al. (2008) Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability. ActaAnaesthesiolScand 52: 561-565.
Badrinath S, Avramov MN, Shadrick M, Ivankovich AD (2000) The use of a ketamine-propofol combination during monitored anesthesia care. AnesthAnalg 90: 858-862.
Arora S (2008) Combining ketamine and propofol ("ketofol") for emergency department procedural sedation and analgesia: a review. West J Emerg Med 9: 20-23.
Coulter FL, Hannam JA, Anderson BJ (2014) Ketofol dosing simulations for procedural sedation. PediatrEmerg Care 30: 621-630.
Loh G, Dalen D (2007) Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department. Ann Pharmacother 41: 485-492.
David H, Shipp J (2011) A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med 57: 435-441.
Phillips W, Anderson A, Rosengreen M, Johnson J, Halpin J (2010) Propofol versus propofol/ketamine for brief painful procedures in the emergency department: clinical and bispectral index scale comparison. J Pain Palliat Care Pharmacother 24: 349-355.
Gerlach AT, Dasta JF (2007) Dexmedetomidine: an updated review. Ann Pharmacother 41: 245-252.
Devasya A, Sarpangala M (2015) Dexmedetomidine: A Review of a Newer Sedative in Dentistry. J ClinPediatr Dent 39: 401-409.
Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD (2000) The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology 93: 382-394.
Dyck JB, Maze M, Haack C, Azarnoff DL, Vuorilehto L, et al. (1993) Computer-controlled infusion of intravenous dexmedetomidine hydrochloride in adult human volunteers. Anesthesiology 78: 821-828.
Ustun Y, Gunduz M, Erdogan O, Benlidayi ME (2006) Dexmedetomidine versus midazolam in outpatient third molar surgery. See comment in PubMed Commons below J Oral MaxillofacSurg 64: 1353-1358.
Cheung CW, Ying CL, Chiu WK, Wong GT, Ng KF, et al. (2007) A comparison of dexmedetomidine and midazolam for sedation in third molar surgery. Anaesthesia 62: 1132-1138.
Taniyama K, Oda H, Okawa K, Himeno K, Shikanai K, et al. (2009) Psychosedation with dexmedetomidine hydrochloride during minor oral surgery. AnesthProg 56: 75-80.
Makary L, Vornik V, Finn R, Lenkovsky F, McClelland AL, et al. (2010) Prolonged recovery associated with dexmedetomidine when used as a sole sedative agent in office-based oral and maxillofacial surgery procedures. J Oral MaxillofacSurg 68: 386-391.
Munro HM, Tirotta CF, Felix DE, Lagueruela RG, Madril DR, et al. (2007) Initial experience with dexmedetomidine for diagnostic and interventional cardiac catheterization in children. PaediatrAnaesth 17: 109-112.
Young ET (2005) Dexmedetomidine sedation in a pediatric cardiac patient scheduled for MRI. Can J Anaesth 52: 730-732.
Heard CM, Joshi P, Johnson K (2007) Dexmedetomidine for pediatric MRI sedation: a review of a series of cases. PaediatrAnaesth 17: 888-892.
Jalowiecki P, Rudner R, Gonciarz M, Kawecki P, Petelenz M, et al. (2005) Sole use of dexmedetomidine has limited utility for conscious sedation during outpatient colonoscopy. Anesthesiology 103: 269-273.
Alhashemi JA (2006) Dexmedetomidinevs midazolam for monitored anaesthesia care during cataract surgery. Br J Anaesth 96: 722-726.
Levänen J, Mäkelä ML, Scheinin H (1995) Dexmedetomidine premedication attenuates ketamine-induced cardiostimulatory effects and postanesthetic delirium. Anesthesiology 82: 1117-1125.
Joseph DT (2012) Dexmedetomidine and Ketamine An Effective Alternative for Procedural Sedation? PediatrCrit Care Med 13: 423-427.
Mahmoud M, Tyler T, Sadhasivam S (2008) Dexmedetomidine and ketamine for large anterior mediastinal mass biopsy. PaediatrAnaesth 18: 1011-1013.
Luscri N, Tobias JD (2006) Monitored anesthesia care with a combination of ketamine and dexmedetomidine during magnetic resonance imaging in three children with trisomy 21 and obstructive sleep apnea. PaediatrAnaesth 16: 782-786.
Nelson TM, Xu Z (2015) Pediatric dental sedation: challenges and opportunities. ClinCosmetInvestig Dent 7: 97-106.
Gazal G, Fareed WM, Zafar MS, Al-Samadani KH (2016) Pain and anxiety management for pediatric dental procedures using various combinations of sedative drugs: A review. Saudi Pharm J 24: 379-385.
Krauss B, Green SM (2006) Procedural sedation and analgesia in children. Lancet 367: 766-780.
Kost S, Roy A (2010) Procedural sedation and analgesia in the pediatric emergency department: A Review of sedative pharmacology. Clinical Pediatric Emergency Medicine. 11: 233-243.
McMorrow SP, Abramo TJ (2012) Dexmedetomidine sedation: uses in pediatric procedural sedation outside the operating room. PediatrEmerg Care 28: 292-296.
Neuman G, Koren G (2013) Safety of procedural sedation in pregnancy. J ObstetGynaecol Can 35: 168-173.
Bhoi S, Chandra A, Galwankar S (2010) Ultrasound-guided nerve blocks in the emergency department. J Emerg Trauma Shock 3: 82-88.
Fitch RW, Kuhn JE (2008) Intraarticularlidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review. AcadEmerg Med 15: 703-708.
Newman DH, Azer MM, Pitetti RD, Singh S (2003) When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med 42: 627-635.


Shreyas Royal – good news!
Excellent news – Shreyas Royal will be able to remain in England. He played so well at Hastings last year and we hope he will be back again. He is indeed a tremendous asset to English chess and we wish him well for the future.
New players at Hastings from Asia!


text:
FRANKLYWNOW - Will Maple Season be Short and Sweet?
Will Maple Season be Short and Sweet?
Wednesday, March 11, 2015 7:06 PM EDT
By Jason Weinstein.
Under the sun - and under the gun. Mike Blachek of Sugar Creek Maple Farm in Vestal is off to a late start this maple season. The coldest February on record has kept sap from flowing through his mile-and-a-half of line until Tuesday.
"Today (Wednesday) everybody in New York State is doing the same thing. We're making our start, finally beginning to make syrup," said Blachek.
Blachek is a small retailer. He produced about 90 gallons of syrup last season. He's unsure how much he and others will make this season. Mother Nature determines the end of Maple season when temperatures get too warm, usually late March or early April according to Blachek.
"The key thing is we want to keep it cool. I know everybody wants to see 60-degree weather but maple producers do not want to see 60- and 70-degree weather until the middle of April," said Blachek.
The industry is big business for New York. The state is the country's second-leading producer of maple syrup behind Vermont. The Empire State pumped out 546,000 gallons of the sweet stuff in 2014 - totalling about 18 percent of the country's production.
"Last year we all talked about how cold and nasty it was but we actually made syrup here in the Southern Tier region in January, February, March, and April. All four months we made syrup last year because we'd get a warm spell. This year? No warm spell until two days ago," said Blachek.
Despite what could be a compressed season, Blachek does not anticipate a syrup shortage.
"Maybe for a small producer like me I might run out quicker. But the state has bulk buyers who have lots of syrup and Canada is always willing to help New York State with any shortage of syrup. I can tell you that," said Blachek.
Blachek says at the start of the season it takes about 70 gallons of sap to make one gallon of syrup.
****In Vestal, Jason Weinstein, FOX 40 HD News****


text:
Robert Weisbrod's Story
With more than ten years of experience and a deep love of gardening, it is no wonder that the neighborhood has enjoyed quite a bountiful harvest this year. When asked about the origins of the project, he said gardening has always been a part of his life and it was actually one of the deciding factors when choosing to move into Two Rivers. He figured because of the scale of the community, He could come together with his neighbors and the HOA to start the community gardens.
Creating green space, like the community garden, is critical to community wellbeing. The garden does not only provide a source of delicious produce, but it also can help people save money and build relationships with their neighbors. It's not surprising to see that Robert has an incredibly good sense of planting seeds for the future outside of the garden as well. Robert worked with Chaffee Housing Trust for over two years to make sure he was homebuyer ready. This involved working with staff to make sure he was getting all of the loans and grants he was eligible for, so he could be successful once he moved in.
When asked about what has changed since moving into his home, Robert said he really values the constancy. He knows how much his monthly payments are and he is glad that even in this unstable time he won't be surprised by seeing a sudden increase in rent due to forces outside his control. It's clear that Robert understands the long-term commitment that comes with being a homeowner and is excited to watch both the garden and the community grow in the years to come. Here at Chaffee Housing Trust, we are very thankful for all the great work Robert has done in getting the garden started and are looking forward to enjoying some tasty meals at next year's harvest.
Start your own jounery towards homeowneship today!


Writing a good job description is a vital part of hiring the right person for your business. As a recruiter or hiring manager, the last thing you want is to waste time sifting through resumes of unqualified individuals, or those who are unclear about the job responsibilities. An Administrative Coordinator job description sample enables you to weed through candidates quickly who aren't qualified or don't seem sincerely interested in working for your company. Taking the time to create a well-written job description before the resumes begin to flood in can save you hours sorting through under-qualified applicants.
To help you draft a good job description, we have included an Administrative Coordinator job description sample below.
You will organize, manage, and perform an extensive array of secretarial, administrative, and program support activities on behalf of the Vice President, Assistant Vice President, and other senior officers of the company. You will be the primary point of administrative and operational contact for internal and external communications, often on complicated and confidential matters.
Pacific Coast Green Business Products was founded in 1996 and has since developed into one of the top environmentally friendly business products companies in the Pacific Northwest. Our company provides innovative solutions and insightful strategies for green office products. Our purpose is to lead the industry while inspiring our employees and clients to make the world a greener place. Our mission is to develop successful relationships that benefit our employees, enhances the community, and sustains the company for the future.
When writing an administrative coordinator job description, you should put considerable focus on the responsibilities section. This should be the meatiest section and include the strongest information. Remember that this is the section that is selling the position, so you should go into detail about what candidates' daily tasks will be if they are hired.
The section that explains the administrative coordinator job responsibilities should follow a specific format to ensure it is effective. Using a bulleted list is recommended, and you should aim to have more than five but fewer than nine bullet points. As you can see from the following examples, it is best to use a strong action verb for the first word of each bullet point. This makes the administrative coordinator job description focused on the tasks candidates will do if you hire them and demonstrates what the daily responsibilities are.
The qualifications and skills section is typically the shortest part of your administrative coordinator job description, which often gives it the misconception of being unimportant. On the contrary, this section can determine how many applicants you will receive. If the qualifications are too lenient, you may receive many applications from unqualified candidates, and if they are too strict, the talented candidates may be too intimidated to apply.
When writing the section that outlines administrative coordinator job specifications, it is best to divide them by which are mandatory and which are preferred. Speaking with current administrative coordinators or the hiring manager should help you categorize all qualifications your company has for this position. For example, education, working experience and foreign languages are all examples of common mandatory attributes. Behavioral qualities are most likely preferences to help narrow down that number of people who apply. You should include both kinds of qualifications in your administrative coordinator job description so readers have a good understanding of what you are looking for. Use these examples to get started.
Once you finish writing the job description, follow these straightforward dos and don'ts to ensure that it is correct.
• Do keep the job description brief, concise, and to the point.
• Don't use an excessive amount of keywords in the job description.
• Do use relevant keyword phrases that are likely to produce results.
• Do focus on special skills or niche positions required for the job.
• Do use alternative job titles when appropriate.
• Don't list salary or benefits if it is against company policy.
• Do summarize daily responsibilities in your job description.
• Do market the advantages of the position and company in the job description.
• Do use bullet points to make it easy to spot relevant points in the description.
• Do include the location of the job.
The easier you make it for a job seeker to answer questions and submit a resume, the more apt you are to attract the top talent for your organization. Your job of recruiting the best candidate for an Administrative Coordinator position is easier when you write a clear job description.


text:
Jonathan Hacker
Jon Hacker chairs O'Melveny's Supreme Court and Appellate Litigation Practice and resides in the firm's Washington, DC office.
Top-ranked by Chambers USA since 2012, Jon is regarded by peers as "a phenomenal writer" and "a forceful advocate." He has authored briefs in dozens of US Supreme Court cases at both the merits and certiorari stages. He has argued six cases in the US Supreme Court and appeals in every federal circuit. He has also briefed and argued appeals in numerous state courts, including New York, California, Ohio, Pennsylvania, Florida, Massachusetts, New Jersey, Maine, Montana, Nebraska, and the District of Columbia. Clients praise him as "such a down-to-earth person but an unparalleled oral advocate."
Jon's appellate work has resulted in reversals of trial-court judgments (including jury verdicts) worth tens of millions and even billions of dollars. He has also briefed and argued many trial-level matters, has conducted discovery and depositions in complex litigation matters, and has handled several trials. Jon earns repeated praise for his "outstanding written product," with peers in the field impressed by his "bullet-proof performances in difficult cases."
Jon's areas of expertise include federal constitutional law, insurance, ERISA, criminal law and procedure, and federal jurisdiction and procedure. He is highly regarded by leading industry publications, including the American Lawyer as "Litigator of the Week", Wall Street Journal as a "Rising Appellate Star", National Law Journal as "Appellate Lawyer of the Week", Chambers USA and Legal 500 as a leading nationwide practitioner, Benchmark Litigation as a "Local Litigation Star", and Best Lawyers in America as a recognized lawyer since 2010.
Jon was a Lecturer in appellate advocacy for five years at the Harvard Law School, where he co-founded and co-directed the HLS Supreme Court and Appellate Advocacy Clinic. He is Co-Chair of the Supreme Court Amicus Committee of the National Association of Criminal Defense Lawyers.
Recognized by Best Lawyers® 2022 for Appellate Practice in Washington, DC; Jon has been listed in Best Lawyers® since 2010
Recognized by Chambers USA for Appellate Law (2021)
Recognized by The Legal 500 US as a Leading Lawyer for Appellate (2020); Listed in The Legal 500 US since 2017
Repeatedly selected as a leading US appellate lawyer by Chambers
"Superstar Of Insurance Law," Insurance Business Magazine (2021)
"Local Litigation Star," Benchmark Litigation (2018-2020)
"Litigator of the Week," The American Lawyer (August 2015)
"Rising Appellate Star," The Wall Street Journal (January 2011)
"Appellate Lawyer of the Week," National Law Journal (2011)
All federal circuit courts of appeal
University of Michigan, J.D., 1995: magna cum laude; Order of the Coif; Henry M. Campbell Memorial Scholarship (Law School's highest award for graduates); Managing Editor, 1994-95, Associate Editor, 1993-94, Michigan Law Review; Winner, Campbell Moot Court Competition, 1994
Harvard College, A.B., 1990 (Social Studies): cum laude
Honorable Bruce M. Selya, US Court of Appeals, First Circuit
Co-Chair, National Association of Criminal Defense Lawyers, Supreme Court Amicus Committee
Barrister, Edward Coke Appellate Inn of Court
Co-Founder and Co-Director
HLS Supreme Court and Appellate Advocacy Clinic, Harvard Law School
Law360: Netflix Improperly Poached Fox Execs, Calif. Panel Says
Insurance Business Magazine: 5-Star Law Firms and Lawyers
Law360: The Funniest Moments Of The Supreme Court's Term
Law360: The Firms That Won Big At The Supreme Court
The National Law Journal: General Litigation Finalist: O'Melveny & Myers
Law360: Stay In Your Lane, High Court Tells Feds In Bridgegate
Bloomberg Law: Scope of Foreign Arbitration in GE Unit Case Divides Justices
Law360: Justices Zero In On Consent In Steel Plant Arbitration Fight
Supreme Court Brief: Argument Today: International Arbitration
More than 50 O'Melveny Lawyers Recognized by Best Lawyers in America® 2022
O'Melveny Practices, Lawyers Highly Ranked by The Legal 500 US 2021
More than 40 O'Melveny Lawyers Recognized in 35+ Practices by Best Lawyers in America® 2021
O'Melveny Practices, Lawyers Highly Ranked in The Legal 500 US 2020
O'Melveny Overturns Convictions for Humanitarian Aid Workers on US-Mexico Border
Alerts and Publications
USPTO Provides Guidance on Director Authority to Rehear IPR Patentability Decisions
jhacker@omm.com


The Ruakituri River is a river of the Gisborne Region of New Zealand's North Island. A major tributary for the Wairoa River, it initially flows northeast from its sources north of Lake Waikareiti. It turns southeast for the majority of its course, reaching the Wairoa at the settlement of Te Reinga, 25 kilometres (16 mi) north of Wairoa.


Download "Intelligent Government From Data to Decision. Robert Lindsley robert.lindsley@oracle.com Oracle, Public Sector Technology Group"
General Session Oracle Business Analytics Executive Briefing Balaji Yelamanchili Senior Vice President, Product Development September 29, 2014 Copyright 2014, Oracle and/or its affiliates. All rights reserved.


Many months ago I had saved a video on Facebook of how to make this Italian cake. Now, at last, I have given it a try; I used to live in Italy myself and I remember how much they liked and used "panna" everywhere, which is basically cream (heavy/whipping cream). The original recipe is from the "An Italian in my Kitchen" baking blog.
Use an electric mixer to beat the eggs and powdered sugar until it's light and airy. Then melt your butter and let it cool while you carry on with the other steps. Sift the flour, vanilla, baking powder, and salt into one bowl. Next, fold the cream into the egg mixture with a spatula, alternating with the dry ingredients. Grate one lemon and add the zest into the batter, finishing off by mixing in the melted butter. As you can see, the preparation requires very minimal effort and is suitable for even beginners. Pour the batter into a silicone bundt cake form and bake at 180°C/350°F for 40-50 minutes; I checked in at 40 minutes and kept it in for another 10 minutes. Serve with powdered sugar!


This protein is involved in the pathway thyroid hormone biosynthesis, which is part of Hormone biosynthesis.
View all proteins of this organism that are known to be involved in the pathway thyroid hormone biosynthesis and in Hormone biosynthesis.
"Monocytic cells derived from human embryonic stem cells and fetal liver share common differentiation pathways and homeostatic functions."
Klimchenko O., Di Stefano A., Geoerger B., Hamidi S., Opolon P., Robert T., Routhier M., El-Benna J., Delezoide A.L., Boukour S., Lescure B., Solary E., Vainchenker W., Norol F.
"Structure of the human thyroid peroxidase gene: comparison and relationship to the human myeloperoxidase gene."
Kimura S., Hong Y.S., Kotani T., Ohtaki S., Kikkawa F.
Cited for: NUCLEOTIDE SEQUENCE [GENOMIC DNA] (ISOFORM 1).
An alternative splicing in the thyroperoxidase mRNA can cause Graves' disease.
"Identification of five novel inactivating mutations in the human thyroid peroxidase gene by denaturing gradient gel electrophoresis."
Bikker H., Vulsma T., Baas F., de Vijlder J.J.M.
Cited for: VARIANTS TDH2A ASP-453; SER-590 AND LYS-799, VARIANTS SER-257; SER-373; THR-398 AND PRO-725.
"Molecular analysis of mutated thyroid peroxidase detected in patients with total iodide organification defects."
Bikker H., Baas F., De Vijlder J.J.M.
Cited for: VARIANT TDH2A PHE-447.
"A novel mutation in the TPO gene in goitrous hypothyroid patients with iodide organification defect."
Santos C.L.S., Bikker H., Rego K.G.M., Nascimento A.C., Tambascia M., De Vijlder J.J.M., Medeiros-Neto G.
Cited for: VARIANT TDH2A GLU-660.
"Two different mutations in the thyroid peroxidase gene of a large inbred Amish kindred: power and limits of homozygosity mapping."
Pannain S., Weiss R.E., Jackson C.E., Dian D., Beck J.C., Sheffield V.C., Cox N., Refetoff S.
Cited for: VARIANTS TDH2A GLN-648 AND LYS-799.
"A novel mutation in the human thyroid peroxidase gene resulting in a total iodide organification defect."
Kotani T., Umeki K., Yamamoto I., Maesaka H., Tachibana K., Ohtaki S.
Cited for: VARIANT TDH2A ASN-240, CHARACTERIZATION OF VARIANT TDH2A ASN-240.
"Two decades of screening for congenital hypothyroidism in The Netherlands: TPO gene mutations in total iodide organification defects (an update)."
Bakker B., Bikker H., Vulsma T., de Randamie J.S.E., Wiedijk B.M., De Vijlder J.J.M.
Cited for: VARIANTS TDH2A THR-326; PHE-447; ASP-453; CYS-527; TRP-693 AND LYS-799.
"Novel mutations of the thyroid peroxidase gene in patients with permanent congenital hypothyroidism."
Ambrugger P., Stoeva I., Biebermann H., Torresani T., Leitner C., Grueters A.
Cited for: VARIANTS TDH2A PRO-458 AND HIS-491.
"Two novel missense mutations in the thyroid peroxidase gene, R665W and G771R, result in a localization defect and cause congenital hypothyroidism."
Umeki K., Kotani T., Kawano J., Suganuma T., Yamamoto I., Aratake Y., Furujo M., Ichiba Y.
Cited for: VARIANTS TDH2A TRP-665 AND ARG-771, CHARACTERIZATION OF VARIANTS TDH2A TRP-665 AND ARG-771.
"High prevalence of a novel mutation (2268 insT) of the thyroid peroxidase gene in Taiwanese patients with total iodide organification defect, and evidence for a founder effect."
Niu D.-M., Hwang B., Chu Y.-K., Liao C.-J., Wang P.-L., Lin C.-Y.
Cited for: VARIANT TDH2A PRO-53.
"Mutation analysis of thyroid peroxidase gene in Chinese patients with total iodide organification defect: identification of five novel mutations."
Wu J.-Y., Shu S.-G., Yang C.-F., Lee C.-C., Tsai F.-J.
Cited for: VARIANTS TDH2A SER-493 AND TYR-796.
"Genetics of specific phenotypes of congenital hypothyroidism: a population-based approach."
Calaciura F., Miscio G., Coco A., Leonardi D., Cisternino C., Regalbuto C., Bozzali M., Maiorana R., Ranieri A., Carta A., Buscema M., Trischitta V., Sava L., Tassi V.
Cited for: VARIANT TDH2A ILE-839.
"Partial iodide organification defect caused by a novel mutation of the thyroid peroxidase gene in three siblings."
Kotani T., Umeki K., Kawano J., Suganuma T., Hishinuma A., Ieiri T., Harada S.
Cited for: VARIANTS TDH2A CYS-533 AND ASP-574-575-LEU DEL, CHARACTERIZATION OF VARIANTS TDH2A CYS-533 AND ASP-574-575-LEU DEL.
"Five novel inactivating mutations in the thyroid peroxidase gene responsible for congenital goiter and iodide organification defect."
Rivolta C.M., Esperante S.A., Gruneiro-Papendieck L., Chiesa A., Moya C.M., Domene S., Varela V., Targovnik H.M.
Cited for: VARIANTS TDH2A THR-307; MET-433; LEU-499 AND ARG-808.
"Monoallelic expression of mutant thyroid peroxidase allele causing total iodide organification defect."
Fugazzola L., Cerutti N., Mannavola D., Vannucchi G., Fallini C., Persani L., Beck-Peccoz P.
Cited for: VARIANT TDH2A TRP-693.
"Two novel mutations in the thyroid peroxidase gene with goitrous hypothyroidism."
Tajima T., Tsubaki J., Fujieda K.
Cited for: VARIANT TDH2A LYS-378.
"Goitrous congenital hypothyroidism and hearing impairment associated with mutations in the TPO and SLC26A4/PDS genes."
Pfarr N., Borck G., Turk A., Napiontek U., Keilmann A., Mueller-Forell W., Kopp P., Pohlenz J.
Cited for: VARIANT TDH2A ASP-453.
Cited for: VARIANTS TDH2A HIS-412 AND 596-GLU--LEU-933 DEL.
Disease descriptionA disorder due to defective conversion of accumulated iodide to organically bound iodine. The iodide organification defect can be partial or complete.
Heme is covalently bound through a H2O2-dependent autocatalytic process. Heme insertion is important for the delivery of protein at the cell surface.
Cleaved in its N-terminal part.
"Identification of a novel partner of duox: EFP1, a thioredoxin-related protein."
Wang D., De Deken X., Milenkovic M., Song Y., Pirson I., Dumont J.E., Miot F.
Cited for: INTERACTION WITH DUOX1; DUOX2 AND CYBA.
Note: Lacks exon 10. Found in normal thyroid tissues as well as Graves'tissues. Rapidly degraded after synthesis, does not reach the cell surface. Inactive.
Note: Lacks exon 16. Found in normal thyroid tissues as well as Graves'tissues. Active.
Note: Lacks exon 14. Active.
Note: Lacks exon 8. Does not fold correctly. Does not reach the cell surface.
Note: Lacks exons 10, 12, 13, 14 and 16.
Note: Lacks exons 10 and 16.
Note: Lacks exons 10 and 14.
Cited for: NUCLEOTIDE SEQUENCE [MRNA] (ISOFORM 1), VARIANT SER-257.
"Homo sapiens thyroid peroxidase (TPO) variant mRNA, alternatively spliced sequence."
Hennen G.P., Igout A., Melen L.B.
Cited for: NUCLEOTIDE SEQUENCE [MRNA] (ISOFORM 5), VARIANTS SER-257; PRO-725 AND ALA-847.
"Human thyroid peroxidase: complete cDNA and protein sequence, chromosome mapping, and identification of two alternately spliced mRNAs."
Kimura S., Kotani T., McBride O.W., Umeki K., Hirai K., Nakayama T., Ohtaki S.
Cited for: NUCLEOTIDE SEQUENCE [MRNA] (ISOFORMS 1 AND 2), VARIANTS PRO-725 AND ALA-847.
"Complete nucleotide sequence of the human thyroperoxidase-microsomal antigen cDNA."
Libert F., Ruel J., Ludgate M., Swillens S., Alexander N., Vassart G., Dinsart C.
Cited for: NUCLEOTIDE SEQUENCE [MRNA] (ISOFORM 1), VARIANTS PRO-725 AND ALA-847.
"Increasing diversity of human thyroperoxidase generated by alternative splicing. Characterization by molecular cloning of new transcripts with single- and multispliced mRNAs."
Ferrand M., Le Fourn V., Franc J.-L.
Cited for: PARTIAL NUCLEOTIDE SEQUENCE [MRNA] (ISOFORMS 4; 5; 6; 2-3 AND 2-4), VARIANTS PRO-725 AND ALA-847.
"Nucleotide sequence of the alternatively spliced human thyroid peroxidase cDNA, TPO-2."
Barnett P.S., Banga J.P., Watkins J., Huang G.C., Gluckman D.R.B., Page M.J., McGregor A.M.
"Evidence for an alternate splicing in the thyroperoxidase messenger from patients with Graves' disease."
Zanelli E., Henry M., Charvet B., Malthiery Y.
Cited for: NUCLEOTIDE SEQUENCE [MRNA] OF 670-933 (ISOFORM 3), ALTERNATIVE SPLICING IN GRAVES' DISEASE.
This is version 230 of the entry and version 4 of the sequence. See complete history.


Finance develops policy and provides whole-of-government advice on appropriate governance arrangements for the range of Commonwealth bodies.
The following publications and guides assist Commonwealth bodies with governance issues.
Beneath the Commonwealth entities and companies there are a number of secondary governance structures.The Australian Government Organisations Register (AGOR) provides detailed information on the function, composition and origins of all Commonwealth entities and companies and these other governance structures.
08/01/19 Remove Australian Aged Care Quality Agency Health The Aged Care Quality and Safety Commission (Consequential Amendments and Transitional Provisions) Act 2018 repealed the Australian Aged Care Quality Agency Act 2013 which established the Australian Aged Care Quality Agency. The date of effect was 1 January 2019.
* This is the date that the change was made in the flipchart, not necessarily the date that the change occurred to the entity or company. The Flipchart of Commonwealth entities and companies and the List of Commonwealth entities and companies under the PGPA Act are not legal documents.
11/09/17 Add WSA Co Ltd Infrastructure and Regional Development A new Commonwealth company established on 7 August 2017, prescribed as a government business enterprise on 29 August 2017.
1/07/17 Add Infrastructure and Project Financing Agency (IPFA) Prime Minister and Cabinet An new executive agency, non-corporate Commonwealth entity established on 1 July 2017.
1/07/17 Amend Australian Naval Infrastructure Pty Ltd (ANI) Finance ANI prescribed as a government business enterprise.
1/07/17 Amend Independent Parliamentary Expenses Authority (IPEA) Finance IPEA became a statutory agency from 1 July 2017.
* This is the date that the change was made in the flipchart, not necessarily the date that the change occurred to the entity or company. The Flipchart of Commonwealth entities and companies and List of GGS, PNFC and PFC bodies under the PGPA Act are not legal documents.
The terms 'machinery of government changes' (MoG changes) and 'administrative re-arrangements' are interchangeable and are used to describe a variety of organisational or functional changes affecting the Commonwealth.
movement of functions into, or out of, the Australian Public Service.
More information of MoG changes can be found here.
information on setting up a new entity.
Additional information on the followings topics in the Guide and checklists can be found here.