Multi-tenant Class B, two story office building totaling approximately 120,000 rentable square feet.
Tenants include Children's Hospital, Lesaffre Yeast Corporation, and Upper Iowa University.
The property is well-located among one of Milwaukee's major office submarkets (West Allis) with easy freeway access and a central location.


Why is my Ryzen 1600x showing high idle temps?
My idle is showing as 58-62 in the UEFI BIOS, I cannot monitor the cpu temperature while the PC is running as CPU ID, CPU Z, SPECCY, Asus AI suite and other software do not detect the temperature of the CPU.
I am running the stock ASUS PRIME B350 BIOS should I update the bios? was there an issue with initial CPU temp readings on 1600x?
download this and only use it to check temps. it is the correct temp. and yes update the latest bios it is needed.
Am I correct in saying that the Ryzen Master Software is correct?
While running Prime95 Blend test on all cores I achieved 50C in Ryzen Master after 5 minutes.
I currently cannot boot into the bios ( however it was working earlier) but I will update the bios as soon as possible.
Currently I can only boot into windows 10, If I try to boot into the bios the screen just goes black and says no signal I'll post about it on the Asus Forums and see if they can help.
aida64 and amd ryzen master is correct... you should not use prime 95 .. and if you even did use it you better be darn sure your setup is as solid as a rock.. thats the most hardest stress tester there is. dont use it .. use aida64.
when you update the bios make sure your uefi bios is set to defaults first. optimized defaults ..


"The government has outlined an excellent vision for digital government reform but it's very difficult for agencies to move to the cloud, according to Ian Apperley, IT Consultant and Blogger.
"What we see from the government is a strong will to make a difference, but in reality making a difference is taking a really long time," explained Ian.
Speaking at the recent FWD_LIVE Government Technology Forum, Ian said that cloud is inevitable and will be required to unlock digital transformation, but that central agencies face a raft of challenges and issues that need to be resolved.
Next PostThe War on the United States Tech Giants & Silicon Valley – Does Tech have a God Complex?


Are you planning to sell your products to an international audience? If this is the case, your first consideration needs to be an e-commerce platform. The platform is the power gear that determines your online success. Also, the platform comes with a package of features and tools for enabling you to reach out to your customers. It is the wheel on which your sales ride on. If you make the wrong choice, your dream of selling to the global audience will cripple.
As a webpreneur, your first objective when going online is to sell. You desire to set up an online store and start selling immediately. In this essence, you need a platform that will not stress you in building an online store and start selling. In particular, your goal is having an international e-commerce platform with little difficulties. If all these statements describe your case, Shopify plus should be your choice. This platform allows you to build an e-commerce website within a short duration. You do not require specialized training or skills. You can set up your store with basic computer skills. Hence, creating your website will be a walk in the park.
Indeed, no one likes associating with unknown brands. Every person wants shopping in the top enterprises. You want to buy an iPhone from Apple. Your online shopping happens in Amazon. When it comes to selling online, choosing a top-ranking international e-commerce platform is a good idea. Having a renowned platform will enhance your branding. Shopify plus meets this criterion. Shopify is the leader or the kingmaker in the e-commerce arena. Most entrepreneurs have their online stores housed in it. Hence, if you want to succeed online, you need to associate yourself with this brand.
Are you an enterprise level entrepreneur? Probably, you are worried about selling your products to the global community. If so, Shopify is your best option. This international e-commerce platform offers you the Shopify plus plan. The plan has advanced tools and features to enable you to sell to the global community.


Sin cuts us off not only from God but also from each other. Repentance is not simply about straightening things out with God, it is also about admitting that our sins affect how we treat other people.
There are three components to making a good confession a) taking responsibility for our own wrongdoings (at some stage we need to stop blaming our parents, the church, society etc.), and admitting them, b) being genuinely sorry for our sinful actions and c) making things right for ourselves and for the people we hurt.
Take the opportunity to participate in the penitential services in the parish during the Advent and Lent seasons where prayers and scripture readings are followed by the opportunity for individual confession. These services bring out the community dimension of sin and reconciliation. Sin undermines the Body of Christ and the Sacrament of Reconciliation builds it up.
Confessions are heard after the 10am Mass on Saturday mornings. Penitential services are held after all the weekend Masses on one weekend during the seasons of Lent and Advent; please check the parish newsletter for dates.


text:
Australian Academy announces nominations for the 9th AACTA International Awards
The nominees for 9th AACTA International Awards have been announced, honouring the best achievements in film excellence, regardless of geography.
A total of 15 films received nominations this year with THE IRISHMAN leading the way with six nominations, followed by ONCE UPON A TIME IN HOLLYWOOD with five nominations, then JOKER and PARASITE both receiving four nominations each. The four noteworthy films also compete for the International AACTA Award for Best Film alongside Australian film THE KING, which recently won four Awards at the 2019 AACTA Awards presented by Foxtel in Sydney.
Also recognised at the Sydney-hosted AACTA Awards was Best Film nominee PARASITE, which took home the Award for Best Asian Film presented by Eureka International Group. The film's producer Kwak Sin-ae attended the ceremony in Australia to accept the prestigious award. PARASITE is now one of the most acclaimed films of 2019 winning over 40 International Awards to date.
AACTA International Award nominees, who also received Golden Globe nominations yesterday, include Toni Collette (KNIVES OUT), Nicole Kidman (BOMBSHELL) and Margot Robbie (BOMBSHELL, ONCE UPON A TIME IN HOLLYWOOD), dominating the Best Supporting Actress category this year. This marks a first in AACTA International Awards history that Australians have received four of the five nominations within the same category. This includes another first for AACTA with Robbie's record-breaking double nomination within the same category.
The winner of the Awards will be announced in Los Angeles at the 9th AACTA International Awards Ceremony on Friday 3 January 2020 (PST) and Saturday 4 January 2020 (AEDT).
Please see below or visit here for the full list of nominees:
AACTA International Award for Best Film
AACTA International Award for Best Direction
1917 – Sam Mendes
THE IRISHMAN – Martin Scorsese
JOKER – Todd Phillips
ONCE UPON A TIME IN HOLLYWOOD – Quentin Tarantino
PARASITE – Bong Joon Ho
AACTA International Award for Best Screenplay
THE IRISHMAN – Steven Zaillian
JOJO RABBIT – Taika Waititi
JOKER – Todd Phillips, Scott Silver
PARASITE – Bong Joon ho, Jin Won Han
AACTA International Award for Best Lead Actor
Christian Bale – FORD V FERRARI
Antonio Banderas – PAIN AND GLORY
Robert De Niro – THE IRISHMAN
Adam Driver – MARRIAGE STORY
Joaquin Phoenix – JOKER
AACTA International Award for Best Lead Actress
Awkwafina – THE FAREWELL
Scarlett Johansson – MARRIAGE STORY
Saoirse Ronan – LITTLE WOMEN
Charlize Theron – BOMBSHELL
Renée Zellweger – JUDY
AACTA International Award for Best Supporting Actor
John Lithgow – BOMBSHELL
Al Pacino – THE IRISHMAN
Joe Pesci – THE IRISHMAN
Brad Pitt – ONCE UPON A TIME IN HOLLYWOOD
Song Kang-Ho – PARASITE
AACTA International Award for Best Supporting Actress
Toni Collette – KNIVES OUT
Nicole Kidman – BOMBSHELL
Florence Pugh – LITTLE WOMEN
Margot Robbie – BOMBSHELL
Margot Robbie – ONCE UPON A TIME IN HOLLYWOOD

redpajama_set_name: RedPajamaCommonCrawl


The Empowered to Connect Conference features practical teaching in a safe and supportive community as we work to equip families, churches, and professionals to better serve children impacted by adoption and foster care. It features Trust-Based Relational Intervention (R) (TBRI (R) ) methods developed by Dr. Karyn Purvis and Dr. David Cross from the Karyn Purvis Institute of Child Development (KPICD) at TCU, to help bring attachment and connection in families. The content is ideal for adoptive and foster parents, those considering adoption or foster care, and those who are serving and supporting others, including social workers, agency professionals, church staff and ministry leaders, counselors, and therapists. The two-day conference will be simulcast live on Friday, April 5, and Saturday, April 6.
Additional links about the event.
* Continuing Education Credits for Professionals: All professionals interested in receiving continuing education credit must register through this site.


This standard is issued under the fixed designation F 2286; the number immediately following the designation indicates the year oforiginal adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A superscript epsilon (e) indicates an editorial change since the last revision or reapproval.
1.1 This specification outlines the performance and design requirements for removable mesh safety barriers used for barriers for swimming pools, hot tubs, and spas to reduce the incidence of injuries or death for infants and children up to and including five years of age.
3.1.1 See ANSI/NSPI-8 and Guide F 1908 for specific terms.
3.2.1 grade, n—surfaces including concrete, brick, tile, wood, metal, or similar rigid surface used as foundation for mesh safety barriers.
3.2.2 mesh safety barrier, n—barrier composed of fabric mesh, support posts, hardware, and other assembly components.
4.1 The top of a fence or wall used as a barrier shall be a minimum of 48 in. (1.2 m) above the grade adjacent to the exterior side of the barrier.
designed and fabricated to hinder children's ability to climb.
4.3 Decorative details, if provided or added, shall not afford the ability of children to climb the mesh safety barrier.
the device to 54 in. (1.37 m).
NOTE 1—Hinged gates in accordance with 4.4 are recommended for use with removable mesh fencing for swimming pools, hot tubs, and spas.
4.5 There shall be a clear zone of at least 20 in. (50 cm) between the barrier and pool/spa/hot tub.
4.6 The fence shall have at least 40 % open space to allow visibility from outside to inside of the pool area.
NOTE 2—The "open space" is calculated by using total area and subtracting the area of opaque supports and mesh.
4.7 The mesh safety barrier shall be removable when desired.
Consumer Products and is the direct responsibility of Subcommittee F15.49 on Pool Safety Standards.
Current edition approved Jan. 1, 2005. Published January 2005.2 For referenced ASTM standards, visit the ASTM website, www.astm.org, or contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM Standards volume information, refer to the standard's Document Summary page on the ASTM website.
1 This guide is under the jurisdiction of ASTM Committee F14 on Fences and is the direct responsibility of Subcommittee F14.10 on Specific Applications. Current edition approved May 1, 2007. Published June 2007. Originallyapproved in 1998. Last previous edition approved in 2006 as F 1908 – 06.
2 For referenced ASTM standards, visit the ASTM website, www.astm.org, or contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM Standards volume information, refer to the standard's Document Summary page on the ASTM website.
4 Available from The Association of Pool and Spa Professionals, 2111 Eisen-hower Avenue, Alexandria, VA 22314.
5 Available from International Code Council, 4051 W. Flossmoor Rd., Country Club Hills, IL 60478–5795.
6 Available from Southern Building Code Congress International, 900 Montclair Rd., Birmingham, AL 35213–1206.
7 Available from American National Standards Institute (ANSI), 25 W. 43rd St., 4th Floor, New York, NY 10036.
Downloaded/printed by William A Jasper (Safety Net International LLC) pursuant to License Agreement. No further reproductions authorized.
terminus of the mesh safety barrier shall be fastened to an upright or vertical member of the enclosure and installed in such a location that the barrier prevents unsupervised access to the pool.
4.9 Vertical posts of the mesh safety barrier shall extend a minimum of 3 in. (7.5 cm) below grade level and shall be spaced no greater than 40 in. (1.016 m) apart.
4.10 The mesh used in the barrier shall have a minimum tensile strength according to Test Method D 5034 of 100 lbf (449 N) and a minimum burst strength in accordance with Test Method D 3787 of 150 lbf (667 N).
G 154 (weatherability, 1000 h).
4.12 When using a molding strip to attach the mesh to the vertical posts, this strip shall contain, at a minimum, #8 31/2-in. screws with a minimum of two screws at the top and two at the bottom with the remaining screws spaced a maximum of 6 in. (15 cm) apart on center.
inside the patio surface shall be of a nonconductive material.
4.14 A latching device shall attach each barrier section at a height no lower than 45 in. (1.14 m) above grade. Common latching devices may include, but are not limited to, devices that provide the security equal to or greater than that of a hook-and-eye-type latch incorporating a spring-actuated retaining lever (commonly referred to as a safety gate hook).
than 1 in. (25 mm) above the deck or installed surface (grade).
at any point, after testing in accordance with Section 5 when the fence is installed in accordance with the manufacturer's instructions.
the mesh at a height of 36 in. (0.91 m) from grade.
5.1.2 A steady vertical force of 20 lb (9 kg) (as measured by any force gage, that is, fish weight scale) shall be exerted steadily upward on the wire.
5.1.3 The force shall be maintained for 1 min.
5.1.4 The mesh safety barrier shall be tested at each 5-ft (1.5-m) increment of the perimeter, including any gate.
5.1.5 Once the load is removed, the mesh safety barrier shall be inspected to determine that no opening exists that would allow passage of a 4.0-in. (102-mm) diameter rigid sphere.
6.1 Height—The top of the fence shall be a minimum of 48 in. [1219 mm] above grade measured on the side of the fence that faces away from the swimming pool. If the fence is mounted on top of an above ground pool, the top of the fence shall be a minimum of 36 in. [914 mm] above the top of the pool structure, provided the top of the pool structure is a minimum of 48 in. [1219 mm] above grade (see 3.2.2 for definition of grade specific to this guide).
6.2 Visibility—The fence on top of an above ground pool shall be so designed and constructed that it has at least a 65 % open area to allow visibility from a designated supervising area outside the pool area to inside the pool area.
6.3 Ground Clearance—The maximum vertical clearance between grade and the bottom of the fence shall be 4 in. [102 mm] measured on the side of the fence that faces away from the swimming pool. Where the top of the pool structure is above grade, such as an above ground pool, the fence may be at ground level or mounted on top of the pool structure. Where the fence is mounted on top of the pool structure, the space between the top of the pool structure and the bottom of the fence shall be no greater than 4 in. [102 mm] in any direction.
5.2.1 The impactor (52 lb) (73 kg), such as in Figs. 2 and 3 from ANSI Z97.1 (see Appendix XI), is prepared and mounted to a 12-in. (30.48-cm) fixture cable so that when at rest it is no farther than 2 in. (50 mm) away from the fence at a height of 36 in. (0.91 m) from grade.
5.2.2 The impactor is swung sideways and upward from the mesh safety barrier until the bottom of the impactor is extended sideways and at a vertical distance of 6 in. (150 mm) above the"at rest" position. The bottom of the impactor will be at 42 in. (1.066 m) above grade for this test.
5.2.3 When all motion has stopped, the impactor is released and allowed to impact once into the mesh safety barrier.
5-ft (1.5-m) increment of the perimeter of the fence including any gate.
passage of a 4.00-in. (102-mm) diameter rigid sphere through or around it at any point.
5.2.6 The latching device shall remain engaged after testing.
6.1 Instructions shall specify all requirements for proper assembly, installation, and use of the mesh safety barrier.
6.2 Instructions shall address all warning signs and safe use.
Use ANSI Z535.4 for guide to details.
6.3 Instructions shall include name, address, and phone number of manufacturer.
7.2 Instructions shall include where the label of compliance is to be placed.
NOTE 3—Suggested location is poolside on first pole of panel (on left side of completed panel facing pool).
4 CPSC Publication 362, "Safety Barrier Guidelines for Home Pools," U.S.
Jersey Community Affairs Division of Codes and Standards Cite 27.
f you feel that your comments have not received a fair hearing you should make your views known to the ASTM Committee on Standards, at the address shown below.


One of the most beloved of all Japanese divinities, the MIZUKO JIZO Buddha takes care of and represents stillborn, miscarried and aborted foetuses. Unique to Japan, the ceremonies surrounding the jizo were created and developed by women. Over the centuries, the image of the mizuko jizo has changed, from a dignified, adult figure, to a serene looking monk-child with a Buddha smile. The jizo has a double purpose. The image both represents the soul of the deceased infant/foetus, and is also the deity who takes care of children on their otherworld journey. The ritual of honouring the foetus or stillborn is called mizuko kuyo. The word mizuko means "water child," or "deceased infant/foetus," and kuyo means "memorial service."
In Japan, water is both an acknowledgement of death and an expression of faith in some kind of rebirth. When the foetus or newborn dies, it goes from the warm waters of the womb to its former liquid state, in which it prepares itself for an eventual rebirth. Historically, mizuko were buried beneath the floorboards of houses, where they were thought to mingle with the water of natural springs, which then carried them to larger bodies of water beneath the surface of the earth, which held special significance as receptacles of life.
The most common days for mizuko kuyo are during the three traditional holidays when offerings are made to ancestors: bon in the summer, and at the spring and summer equinoxes. The mizuko kuyo can be performed in different ways. Many Buddhist temples in Japan have special sections where a woman who can afford to may buy a tomb for her mizuko. The tomb consists of a stone, on top of which stands a carved figure of a jizo, generally wearing a red bib, and carrying a staff with rings or a stick with bells on top (which he uses to help the mizuko who can't yet walk). On the stone is written a kaimyo - a name given to a person after death.
These sites are not somber graveyards. In fact, they are often quite "happy" places. Some of the cemeteries are equipped with playgrounds for children. While the children play, women (and sometimes men) bow, observe moments of silence, and ladle water over the mizuko jizo in an act of ritual cleansing. At times they may light a candle or a few sticks of incense, decorate the tombs with flowers, pinwheels and other toys, drape garments over the jizo, and even erect umbrellas over his head to keep off the rain.
In Japan, abortion is seen as a necessary sorrow, a painful social necessity, and a means for protecting what are felt to be "family values." Some Buddhists worry that abortions could become trivialized, which would lead to a hardening of people's hearts. The mizuko kuyo serves a positive, therapeutic role, keeping people in touch with their emotions and their loss.


Stomaflex liquid catalyst now available on Clinicaid.com.ng. Call us now.
Stomaflex liquid catalyst now available on Clinicaid.com.ng. Call us to place your bulk order now. We deliver to all the states in Nigeria.
Stomaflex gel catalyst now available on Clinicaid.com.ng. Call us to place your bulk order now. We deliver to all the states in Nigeria.
Hiflex- RR Denture repair and relining material (self cure) now available on Clinicaid.com.ng. Place your order now.
Direct Pulp Capping material now available in Nigeria on Clinicaid.com.ng. Place your order now.
Zinc Phosphate cement now available on Clinicaid.com.ng. Call us to place your bulk order now.
SLICKGEL, Root canal file lubricating gel now available on Clinicaid.com.ng. Call us to place your bulk order now. We deliver to all the states in Nigeria.


The Klamath County Fairgrounds' mission revolves around the entire Klamath Basin. Persons of all ages use the facilities that we offer for all types of community and livestock events at an affordable and economic price. The Fairgrounds is a vital resource for personal development, along with the key focus of education where the year round activities constitute a living classroom for all persons involved.


text:
Reproducible Science
Perioperative Medicine| May 2016
Severe Nausea and Vomiting in the Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia II Trial
Paul S. Myles, M.B., B.S., M.P.H., M.D., F.C.A.I., F.A.N.Z.C.A., F.R.C.A., F.A.H.M.S.;
Paul S. Myles, M.B., B.S., M.P.H., M.D., F.C.A.I., F.A.N.Z.C.A., F.R.C.A., F.A.H.M.S.
From the Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Monash University, Melbourne, Victoria, Australia (P.S.M.); Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, People's Republic of China (M.T.V.C.); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (J.K., A.F.); Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia (M.J.P.); School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia (M.J.P.); Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (K.L.); Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Victoria, Australia (K.L.); Department of Pharmacology and Therapeutics, University of Melbourne, Melbourne, Victoria, Australia (K.L.); Department of Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia (P.J.P.); Institute for Breathing and Sleep, Victoria, Australia (P.J.P.); Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio (D.I.S.); Department of Anaesthesia, Intensive Care and Pharmacology, Geneva University Hospitals, University of Geneva, Switzerland (G.H.); Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada (W.S.B.); Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada (W.S.B.); Department of Anesthesia, Perioperative and Acute Pain Management, Barwon Health, Geelong, Victoria, Australia (C.O.); and Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom (J.R.S.).
Address correspondence to Dr. Myles: Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Commercial Road, Melbourne, Victoria 3004, Australia. p.myles@alfred.org.au. This article may be accessed for personal use at no charge through the Journal Web site, www.anesthesiology.org.
Matthew T. V. Chan, M.B., B.S., Ph.D., F.A.N.Z.C.A., F.H.K.C.A.;
Matthew T. V. Chan, M.B., B.S., Ph.D., F.A.N.Z.C.A., F.H.K.C.A.
Jessica Kasza, B.Sc., Ph.D.;
Jessica Kasza, B.Sc., Ph.D.
Michael J. Paech, M.B., B.S., D.M., F.A.N.Z.C.A., F.F.P.M.A.N.Z.C.A., F.R.A.N.Z.C.O.G.;
Michael J. Paech, M.B., B.S., D.M., F.A.N.Z.C.A., F.F.P.M.A.N.Z.C.A., F.R.A.N.Z.C.O.G.
Kate Leslie, M.B., B.S., M.D., M.Epi., M.Hlth.Serv.Mt., F.A.N.Z.C.A.;
Kate Leslie, M.B., B.S., M.D., M.Epi., M.Hlth.Serv.Mt., F.A.N.Z.C.A.
Philip J. Peyton, M.B., B.S., M.D., Ph.D., F.A.N.Z.C.A.;
Philip J. Peyton, M.B., B.S., M.D., Ph.D., F.A.N.Z.C.A.
Daniel I. Sessler, M.D.;
Daniel I. Sessler, M.D.
Guy Haller, M.D., M.Sc., Ph.D.;
Guy Haller, M.D., M.Sc., Ph.D.
W. Scott Beattie, M.D., Ph.D.;
W. Scott Beattie, M.D., Ph.D.
Cameron Osborne, M.B., B.S., F.A.N.Z.C.A.
J. Robert Sneyd, M.B., M.Chir., M.A., M.D., F.R.C.A.;
J. Robert Sneyd, M.B., M.Chir., M.A., M.D., F.R.C.A.
Andrew Forbes, M.Sc., Ph.D.
This article has been selected for the Anesthesiology CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue.
This article is featured in "This Month in Anesthesiology," page 1A.
Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal's Web site (www.anesthesiology.org).
This article has an audio podcast.
Submitted for publication July 26, 2015. Accepted for publication January 25, 2016.
Anesthesiology May 2016, Vol. 124, 1032–1040.
https://doi.org/10.1097/ALN.0000000000001057
Paul S. Myles, Matthew T. V. Chan, Jessica Kasza, Michael J. Paech, Kate Leslie, Philip J. Peyton, Daniel I. Sessler, Guy Haller, W. Scott Beattie, Cameron Osborne, J. Robert Sneyd, Andrew Forbes; Severe Nausea and Vomiting in the Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia II Trial. Anesthesiology 2016; 124:1032–1040 doi: https://doi.org/10.1097/ALN.0000000000001057
The Evaluation of Nitrous oxide in the Gas Mixture for Anesthesia II trial randomly assigned 7,112 noncardiac surgery patients to a nitrous oxide or nitrous oxide–free anesthetic; severe postoperative nausea and vomiting (PONV) was a prespecified secondary end point. Thus, the authors evaluated the association between nitrous oxide, severe PONV, and effectiveness of PONV prophylaxis in this setting.
Univariate and multivariate analyses of patient, surgical, and other perioperative characteristics were used to identify the risk factors for severe PONV and to measure the impact of severe PONV on patient outcomes.
Avoiding nitrous oxide reduced the risk of severe PONV (11 vs. 15%; risk ratio [RR], 0.74 [95% CI, 0.63 to 0.84]; P < 0.001), with a stronger effect in Asian patients (RR, 0.55 [95% CI, 0.43 to 0.69]; interaction P = 0.004) but lower effect in those who received PONV prophylaxis (RR, 0.89 [95% CI, 0.76 to 1.05]; P = 0.18). Gastrointestinal surgery was associated with an increased risk of severe PONV when compared with most other types of surgery (P < 0.001). Patients with severe PONV had lower quality of recovery scores (10.4 [95% CI, 10.2 to 10.7] vs. 13.1 [95% CI, 13.0 to 13.2], P < 0.0005); severe PONV was associated with postoperative fever (15 vs. 20%, P = 0.001). Patients with severe PONV had a longer hospital stay (adjusted hazard ratio, 1.14 [95% CI, 1.05 to 1.23], P = 0.002).
The increased risk of PONV with nitrous oxide is near eliminated by antiemetic prophylaxis. Severe PONV, which is seen in more than 10% of patients, is associated with postoperative fever, poor quality of recovery, and prolonged hospitalization.
Nitrous oxide increased the risk of severe postoperative nausea and vomiting, more so in Asian subjects; the effect was eliminated by pretreatment with an antiemetic. Severe postoperative nausea and vomiting was associated with fever, poor quality of recovery, and increased hospital stay, indicating that its prevention is clinically important.
Supplemental Digital Content is available in the text.
What We Already Know about This Topic
Nitrous oxide is a known risk factor for postoperative nausea and vomiting (PONV), but its role in severe (persistent or recurrent) PONV is less clear
The risk factors for severe PONV were examined by a secondary analysis of data from the Evaluation of Nitrous oxide in the Gas Mixture for Anesthesia II trial that randomized subjects undergoing noncardiac surgery to receive nitrous oxide or nitrous oxide–free anesthetic
What This Article Tells Us That Is New
Nitrous oxide increased the risk of severe postoperative nausea and vomiting (PONV), more so in Asian subjects; the effect was eliminated by pretreatment with an antiemetic
Severe PONV was associated with fever, poor quality of recovery, and increased hospital stay, indicating that its prevention is clinically important
NITROUS oxide is a well-recognized risk factor for postoperative nausea and vomiting (PONV),1–3 particularly in more extensive surgical procedures in which exposure to nitrous oxide is prolonged.3 Most episodes of PONV are transient and perhaps insignificant; in contrast, persistent or recurrent PONV has distinct clinical importance.4,5 However, most studies characterizing any PONV or the effectiveness of antiemetic regimens have focused on minor and ambulatory surgery. In this study, we focused on protracted and/or repeat episodes of PONV occurring up to 3 days after surgery.
We recently completed the Evaluation of Nitrous oxide in the Gas Mixture for Anesthesia (ENIGMA) II trial, which confirmed the cardiovascular safety of nitrous oxide in 7,112 at-risk patients having major noncardiac surgery in 45 participating centers from 10 countries. The incidence of severe PONV was recorded prospectively as a prespecified secondary end point, and we demonstrated the higher rates of PONV in those receiving nitrous oxide.6 Furthermore, we demonstrated that antiemetic prophylaxis could mitigate this risk.6 Therefore, we explored the risk of severe PONV in those receiving a nitrous oxide or nitrous oxide–free anesthetic according to the prespecified subgroups, and we calculated the incidence, risk factors, and effectiveness of PONV prophylaxis for severe PONV in patients who participated in the ENIGMA-II trial.
Our primary hypothesis was that there was an association between severe PONV and patient outcomes, including quality of recovery (QoR), fever, wound infection, and hospital stay.
ENIGMA-II trial was registered at ClinicalTrials.gov (number: NCT00430989; principal investigator: P.S.M.; date of registration: January 31, 2007). The trial protocol was approved by the institutional review board at each site (sponsor site: Alfred Health Ethics Committee), and written informed consent was obtained from participating patients. Protocol details have been published.6,7 Briefly, we enrolled patients aged 45 yr or older with known or suspected coronary artery disease who were scheduled to have general anesthesia for surgery lasting at least 2 h. Patients having cardiac surgery or requiring one-lung ventilation or in whom nitrous oxide was contraindicated in the opinion of the attending anesthesiologist (e.g., current bowel obstruction, history of severe PONV), were excluded.
Randomization was performed using a computer-generated code, accessed via an automated telephone voice recognition service. Treatment assignment was stratified by site using permuted blocks. For patients assigned to nitrous oxide, anesthesiologists were asked to give nitrous oxide at an inspired concentration of 70% in 30% oxygen; for patients assigned to no nitrous oxide, anesthesiologists were asked to use an air–oxygen mixture at an inspired oxygen concentration of 30%. In either case, the designated gas was started shortly after induction of anesthesia and tracheal intubation or laryngeal mask insertion and was continued until completion of surgery.
The choice of anesthetic, analgesic, and antiemetic drugs was left to the discretion of the attending anesthesiologist. Attending anesthesiologists were aware of group assignment, but allocation was concealed from the surgeons, patients, and staff responsible for postoperative data collection and outcome assessment.
Preoperative demographic characteristics and details of patient medical and surgical history were recorded. Asian ethnicity was implied for all patients enrolled in Hong Kong, Malaysia, and Singapore study sites. We calculated a modified PONV risk score based on the validated criteria8,9 that included sex (female = 1, male = 0), age (less than 50 yr = 1, more than or equal to 50 yr = 0), smoking status (nonsmoker = 1, smoker = 0), and use of postoperative opioids (yes = 1, no = 0); the latter criterion was scored as 1 in all patients receiving intraoperative morphine, and so scores ranged from 1 (low risk) to 4 (high risk).
Fever was defined as any recorded temperature more than or equal to 38°C within 3 days of surgery. Postoperative wound infection was defined by the Centers for Disease Control and Prevention description of surgical site infection (i.e., purulent drainage, or positive microbial culture from the incision, or documented wound infection in medical record) within 30 days of surgery.10
The primary outcome measure was severe PONV. This was assessed at 24 h after surgery by a face-to-face interview, and data were confirmed with medical record review. Severe PONV was defined as two or more episodes of nausea and/or expulsion of gastric contents, at least 6 h apart, or requiring treatment with at least three doses of at least two different classes of antiemetic medication in any 24-h period during the 3 days after surgery. We did not collect data for less severe PONV (mild or transient nausea, single episode of vomiting, or single or repeat doses of same antiemetic therapy). On day 1 after surgery, patients also rated their postoperative QoR using a validated 9-item scale score (QoR score, 0 = worst recovery to 18 = excellent recovery).11
Statistical analyses were conducted according to intention-to-treat principles. Data are presented as mean ± SD, median (interquartile range), or n (%). Nitrous oxide and nitrous oxide–free groups were compared with unadjusted risk ratios (RRs) and 95% CIs using binary regression with a logarithmic link, with the no-nitrous oxide group as the reference category. We compared the baseline characteristics of patients who suffered severe PONV up to 3 days after surgery with those who did not using chi-square or Wilcoxon rank sum tests, as appropriate.
Risk factors for severe PONV were determined using multivariable logistic regression models, including separately those who received PONV prophylaxis or who did not in order to ascertain the risk factor–treatment interaction and to inform clinical practice in either circumstance. In these regression models, the dependent variable was severe PONV on postoperative day 1. The 17 independent variables were prespecified and included age, sex, American Society of Anesthesiologists physical status, body mass index, country, presence of diabetes mellitus, coronary artery disease, regular use of folate/multivitamins or vitamin B12 injection, smoking habits, ethnicity, surgical types, duration of anesthesia, intraoperative exposure to nitrous oxide, propofol infusion, regional block, bispectral index monitoring, and avoidance of morphine administration. Model fit was assessed using area under the receiver operating characteristic curve.
The associations between severe PONV and postoperative fever, wound infection, and adverse events were determined using logistic regression. We compared QoR scores between patients with and without severe PONV using the Wilcoxon rank sum test. The impact of severe PONV on length of hospital stay was assessed using a Cox proportional hazards model.
We determined the efficacy of various prophylactic strategies for severe PONV by calculating the relative risk for severe PONV using a log binomial model. To adjust for the lack of randomization of prophylactic strategies, which led to imbalances between different treatment groups, analyses were adjusted using a propensity score approach.12 The balance of baseline covariates between treatment groups was assessed using the standardized difference, the difference between the percentage (categorical or binary variables) or mean (continuous variables) between groups, divided by the SD, and expressed as a percentage.12 Standardized differences more than 10% in absolute value are taken to be indicative of meaningful imbalances between groups, and inverse probability of treatment weighting was used to account for the differences between groups.
Inverse probability of treatment weighting is a propensity score–based approach, with treatment probabilities estimated using a propensity score model. In the case of categorical treatments, a multinomial logistic regression model was used. These models contained baseline characteristics and were selected iteratively to ensure balance between treatment groups as assessed by the standardized difference, according to recommendations.12 Each patient was weighted by the estimated probability of receiving the treatment that they actually received. A key assumption required for the validity of propensity score–based approaches is that all patients have a positive probability of receiving each treatment.13 Hence, patients with estimated propensity scores higher or lower than those of patients in any other treatment group were excluded from analyses to ensure the comparability of patients across treatment groups; this resulted in 2,257 exclusions for this secondary analysis.
We considered two classifications of prophylactic PONV interventions: (1) classification by number of antiemetic drugs administered (with patients classified as receiving 0, 1, or 2 or more drugs) and (2) classification by type of PONV intervention (classified as patients receiving no antiemetics, dexamethasone, 5-hydroxytryptamine3 [5-HT3] receptor antagonists, or both dexamethasone and 5-HT3 receptor antagonists). Other antiemetic combinations were not tested because there were few patients receiving such combinations.
All analyses were conducted using Stata 12 software (Stata Corporation, USA). All P values were two sided, with P < 0.05 considered to be statistically significant.
Nitrous Oxide and Severe PONV
Patient demographic and perioperative characteristics of those given nitrous oxide or a nitrous oxide–free anesthetic are reported in table 1. There was a small (0.1%) amount of missing PONV outcome data, mostly because of critical illness or early deaths. Patients assigned to the nitrous oxide group were more likely to receive PONV prophylaxis (P < 0.001). Avoiding nitrous oxide reduced the risk of severe PONV (11 vs. 15%; RR, 0.74 [95% CI, 0.63 to 0.84]; P < 0.0001). The emetogenic effect of nitrous oxide was stronger in Asian patients (interaction P = 0.004; RR, 1.89 [95% CI, 1.08 to 2.33], P < 0.001) and in those receiving intraoperative morphine (RR, 1.72 [95% CI, 1.41 to 2.13], P < 0.001; fig. 1). Avoiding nitrous oxide had a smaller effect in non-Asian patients (RR, 0.84 [95% CI, 0.72 to 0.97]). As previously reported,6 avoiding nitrous oxide had a nonsignificant effect on the risk of PONV if antiemetic prophylaxis was used (RR, 0.89 [95% CI, 0.76 to 1.05], P = 0.18).
Patient and Perioperative Characteristics*
Relative risk (bars indicate 95% CI) for severe postoperative nausea and vomiting (PONV) associated with the use of nitrous oxide in selected subgroups. The reported P values refer to tests of interaction. ASA = American Society of Anesthesiologists; BIS = bispectral index; BMI = body mass index.
Figure 1 reports the results of prespecified subgroup analyses of the impact of eliminating nitrous oxide on severe PONV. The protective effect of PONV prophylaxis in those exposed to nitrous oxide was most apparent in Asian patients (further details in the Supplemental Digital Content 1, table 1, http://links.lww.com/ALN/B260).
Risk Factors for Severe PONV
A total of 884 patients (12.4%) had severe PONV within 3 days of surgery. Table 2 reports the comparison of baseline characteristics in patients who did or did not suffer severe PONV; further details are provided in Supplemental Digital Content 1 (tables 2 and 3, http://links.lww.com/ALN/B260), for which the multivariate logistic regression models for severe PONV had areas under the receiver operating characteristic curve of 0.71 (for patients with PONV prophylaxis) and 0.72 (for patients without PONV prophylaxis). Female patients, nonsmokers, gastrointestinal surgery patients, and those having surgery more than 2 h and receiving nitrous oxide were more likely to suffer severe PONV whether or not they received prophylactic antiemetics (fig. 2). Asian patients were not at an increased risk of PONV, despite being less likely to receive PONV prophylaxis (Supplemental Digital Content 1, table 3, http://links.lww.com/ALN/B260).
Risk Factors for Severe PONV Adjusted for All Listed Covariables, for All Patients
Predictive probability of severe postoperative nausea and vomiting (PONV) for patients without PONV prophylaxis, for each combination of anesthetic duration and treatment group (nitrous oxide–free or nitrous oxide anesthetic).
Impact of Severe PONV
Patients with severe PONV had lower QoR scores compared with those who did not (10.4 [95% CI, 10.2 to 10.7] vs. 13.1 [95% CI, 13.0 to 13.2], P < 0.0005). The absolute difference in QoR score, adjusted for age, sex, American Society of Anesthesiologists physical status, use of nitrous oxide, and duration of surgery, was 2.45 (95% CI, 2.20 to 2.70).
Severe PONV was an independent predictor of postoperative fever (5 vs. 20%; adjusted odds ratio, 1.44 [95% CI, 1.17 to 1.77]; P = 0.001). However, it was not associated with wound infection (adjusted odds ratio, 1.20 [95% CI, 0.92 to 1.57]; P = 0.19) and other adverse events (adjusted odds ratio, 1.20 [95% CI, 0.97 to 1.48]; P = 0.093). Nevertheless, patients with severe PONV had a longer hospital stay (median [interquartile range], 7.0 [4.9 to 12.1] days) compared with those who did not (6.0 [3.2 to 10.1] days; adjusted hazard ratio, 1.14 [95% CI. 1.05 to 1.23]; P = 0.002; fig. 3).
Kaplan–Meier estimate of the time-to-discharge function (hospital length of stay [LoS]), comparing patients with and without severe postoperative nausea and vomiting up to 30 days after surgery (Wilcoxon rank sum test, P < 0.0001).
Prophylactic Interventions for Severe PONV
The PONV risk score identified those at higher risk of severe PONV (table 3). Patients at higher risk of PONV were more likely to receive antiemetic prophylaxis (table 4).
Number (%) of Patients with Severe PONV, According to PONV Risk Score
Number (%) of Patients with Any Antiemetic Prophylaxis, According to PONV Risk Score
Asian patients were less likely to receive PONV prophylaxis (286 of 1,398 [21%]) when compared with non-Asian patients (3,680 of 5,585 [66%]). This generally did not increase their risk of PONV, except in those receiving nitrous oxide (Supplemental Digital Content 1, table 1, http://links.lww.com/ALN/B260).
A total of 2,227 (32%) patients were given dexamethasone, 2,728 (39%) were given 5-HT3 receptor antagonists, and 418 (6%) were given droperidol or haloperidol. Thirty-seven percent of patients were given single-drug PONV prophylaxis, 18% were given dual prophylaxis, and 1% were given triple prophylaxis. There was no measurable superior effect of single-drug prophylaxis using dexamethasone, 5-HT3 receptor antagonist, or droperidol/haloperidol on the rates of severe PONV. Similarly, combinations of antiemetic interventions were not associated with reduced risk of severe PONV, whether or not analyses were adjusted using a propensity score (Supplemental Digital Content 1, tables 2 to 8, http://links.lww.com/ALN/B260).
In this preplanned secondary analysis of the ENIGMA-II trial, we found that severe PONV occurred in 12.4% of patients having major noncardiac surgery. Female patients, nonsmokers, gastrointestinal surgery patients, and those having surgery more than 2 h in duration were more likely to suffer severe PONV whether or not they received prophylactic antiemetics. PONV has been regarded by some as a minor inconvenience, primarily because PONV does not necessarily indicate diminished patient satisfaction or functional impairment.14,15 However, our analysis showed that patients with severe PONV had poorer QoR, with a QoR score difference of 2.45 (95% CI, 2.20 to 2.70), which exceeds the direct effect of PONV (maximum 2 point difference) on the QoR score itself, suggesting that strategies to avoid severe PONV are clinically important.
Our subgroup analyses demonstrate that the emetogenic effects of nitrous oxide occurred in a broad range of patient groups and surgeries, suggesting that similar effects are likely to occur in other settings. However, although eliminating nitrous oxide from the anesthetic gas mixture decreased the risk of severe PONV by one third, the absolute reduction was only 4% (a number needed to treat of 25), which is of questionable clinical importance. Furthermore, pretreatment with one or more common antiemetics, such as dexamethasone or a 5-HT3 receptor antagonist, eliminated the effect of nitrous oxide on severe PONV. Based on these results, we believe that concern about severe PONV is not a valid reason to avoid nitrous oxide. We also demonstrated a higher risk of severe PONV with increasing time of exposure to nitrous oxide when surgery is greater than 2 h in duration. The impact of duration of exposure is consistent with a recent pooled analysis of PONV studies evaluating nitrous oxide.3
Although this study confirms the emetogenic properties of nitrous oxide, the mechanism is still debated and may well be multifactorial. Anesthetic drugs, particularly opioids, are commonly implicated in PONV, but genetic and emotional predisposition16 of patients and the underlying inflammatory response to surgery17 all contribute to PONV. PONV, by itself, may aggravate the inflammatory response to surgery and impair wound healing.18
The strengthened association of nitrous oxide with severe PONV among people of Asian ethnicity is a new finding and is of practical importance. Previous studies have shown that people of Asian descent have increased nausea and vomiting after selected types of chemotherapy19 and an increased susceptibility to motion sickness,20 possibly associated with an increase in vasopressin concentrations.20 Therefore, anesthesiologists should consider people of Asian descent at a higher risk of severe PONV when using nitrous oxide. We also found that Asian patients had greater risk of PONV on univariate testing (Supplemental Digital Content 1, table 2, http://links.lww.com/ALN/B260), but this largely disappeared after adjustment of other variables (especially nonsmoking status) and was not an independent risk (table 2). Nevertheless, Asian patients were less likely to receive PONV prophylaxis, and this should be rectified in future.
Our study found that gastrointestinal surgery of at least 2 h in duration was an independent risk factor for severe PONV. Although some types of surgery have been implicated as risk factors for PONV, only laparoscopic and gynecologic surgeries are currently identified in the most recent guidelines.1 Anatomically, intraoperative manipulation of gastrointestinal tract enhances serotonin release from the enterochromaffin cells and might increase the risk of severe PONV.21 Our findings provide strong support for routine PONV prophylaxis in all patients undergoing gastrointestinal surgery that is expected to last at least 2 h.
We found that severe PONV was associated with postoperative fever. Although this does not imply a causal relationship, both postoperative fever and severe PONV may serve as indicators for impending complications. Increased levels of cytokines may be a common cause for both,22 and often this will be related to the amount of tissue damage from the surgery.23 More importantly, patients with severe PONV had a longer hospital stay, suggesting that severe PONV has both functional and cost consequences.
Limitations and Strengths
We did not include a history of PONV or motion sickness in our risk models. We have not adjusted for the multiple comparisons and although this was a preplanned secondary analysis of the ENIGMA-II trial, it is likely that some statistically significant findings may be spurious. We could not identify a statistically significant association between nitrous oxide and wound infection, but the point estimate indicated a 20% increased risk, and so it is possible that we missed a true effect because of inadequate study power for this uncommon complication.
We did not study lesser degrees of PONV in which symptoms did not require any treatment or resolved with a single antiemetic drug administration. In contrast to previous studies,9 we were unable to demonstrate additive antiemetic effects of propofol-based anesthesia, dexamethasone, 5-HT3 receptor antagonists, and haloperidol or droperidol in ENIGMA-II trial patients. Consistent with this, there was no significant difference in severe PONV whether one or more prophylactic antiemetics were given. We offer two explanations for these findings. First, patients were not randomly assigned to the use of antiemetic prophylaxis, and propensity-based methods may not account for residual confounding. Second, the recommended dosage of common antiemetics may only prevent less severe symptoms. In a cluster-randomized trial that evaluated the implementation of a PONV prediction model, additional prophylactic antiemetics did not reduce the incidence of PONV over and above using a single antiemetic.24
The main strengths of our study are that we included 7,112 patients from 45 sites in 10 countries and achieved complete follow-up in 99.9% of patients. We have focused on severe PONV, using criteria that are known to be clinically important.4 The subgroup findings suggest that the results are likely to be generalizable to other surgical populations.
Nitrous oxide increases the risk of severe PONV by only a small percentage, and the increased risk is essentially eliminated by antiemetic drug prophylaxis. Concern about severe PONV thus does not appear to be a valid reason to avoid nitrous oxide. Nitrous oxide–induced severe PONV was more likely to occur in Asian patients. Severe PONV was more likely in those undergoing gastrointestinal surgery. Severe PONV, which is seen in more than 10% of patients, is associated with postoperative fever, poor QoR, and prolonged hospitalization.
This study was supported by the Australian National Health and Medical Research Council (Canberra, Australian Capital Territory, Australia), the Australian New Zealand College of Anaesthetists (Melbourne, Victoria, Australia), and the Heart and Stroke Foundation of Canada (Ottawa, Ontario, Canada).
Dr. Paech has received funding from MSD Schering-Plough Pty Ltd., Macquarie Park, New South Wales, Australia. The other authors declare no competing interests.
Full protocol available from Dr. Myles: p.myles@alfred.org.au. Raw data available from Dr. Myles: p.myles@alfred.org.au.
Diemunsch
Kranke
Candiotti
Lagoo-Deenadayalan
Nezat
Tramèr
Society for Ambulatory Anesthesia
Consensus guidelines for the management of postoperative nausea and vomiting.
Anesth Analg
Paech
ENIGMA Trial Group
Risk factors for severe postoperative nausea and vomiting in a randomized trial of nitrous oxide-based vs nitrous oxide-free anaesthesia.
Br J Anaesth
Nitrous oxide-related postoperative nausea and vomiting depends on duration of exposure.
Wengritzky
Simplified postoperative nausea and vomiting impact scale for audit and post-discharge review.
Gde L
El-Moalem
Lubarsky
How much are patients willing to pay to avoid postoperative nausea and vomiting?
Sessler
Silbert
Schricker
ANZCA Trials Group for the ENIGMA-II Investigators
The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): A randomised, single-blind trial.
Jamrozik
Badner
ANZCA Trials Group
Nitrous oxide and perioperative cardiac morbidity (ENIGMA-II) Trial: Rationale and design.
Am Heart J
94.e1
Läärä
Greim
Roewer
A simplified risk score for predicting postoperative nausea and vomiting: Conclusions from cross-validations between two centers.
Risk factors for postoperative nausea and vomiting.
Horan
Dudeck
CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting.
Am J Infect Control
Tanil
Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults.
Introduction to propensity scores.
van der Laan
Diagnosing and responding to violations in the positivity assumption.
Stat Methods Med Res
The "big little problem" of postoperative nausea and vomiting: Do we know the answer yet?
Surrogate outcomes: They don't get it.
994; author reply 994–5
Joy Lin
Tseng
Sequence variants of the HTR3A gene contribute to the genetic prediction of postoperative nausea in Taiwan.
J Hum Genet
Multi-dose parecoxib provides an immunoprotective effect by balancing T helper 1 (Th1), Th2, Th17 and regulatory T cytokines following laparoscopy in patients with cervical cancer.
Mol Med Rep
Postoperative nausea and vomiting.
Surg Clin North Am
Bourdeanu
Somlo
Luu
Chemotherapy-induced nausea and vomiting in Asian women with breast cancer receiving anthracycline-based adjuvant chemotherapy.
J Support Oncol
Uijtdehaage
Asian hypersusceptibility to motion sickness.
Hum Hered
Mechanisms underlying postoperative nausea and vomiting and neurotransmitter receptor antagonist-based pharmacotherapy.
Shimokawa
Nunomura
Miyata
Van Lint
High affinity receptor for IgE stimulation activates protein kinase D augmenting activator protein-1 activity for cytokine producing in mast cells.
Int Immunopharmacol
Dauleh
Townell
Open versus laparoscopic cholecystectomy: A comparison of postoperative temperature.
J R Coll Surg Edinb
van Wolfswinkel
Kalkman
Vergouwe
van Klei
Impact of risk assessments on prophylactic antiemetic prescription and the incidence of postoperative nausea and vomiting: A cluster-randomized trial.
Copyright © 2016, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.
Antiemetic Prophylaxis Does Not Improve Outcomes after Outpatient Surgery When Compared to Symptomatic Treatment
Anesthesiology (February 1999)
Nitrous Oxide–related Postoperative Nausea and Vomiting Depends on Duration of Exposure
The Dose-Response Relation and Cost-effectiveness of Granisetron for the Prophylaxis of Pediatric Postoperative Emesis
Antiemetic Prophylaxis for Office-based Surgery: Are the 5-HT3Receptor Antagonists Beneficial?
Can Postoperative Nausea and Vomiting Be Predicted?


We are a fourth generation, family-owned business, serving Nassau and Suffolk since 1945. We pride ourselves on the quality flooring and window treatment products we provide our community, year after year.
We are a company with strong ethical values, and we strive to make the customer our number one priority. Our staff is dedicated to servicing our customers, delivering the highest level of service possible.
We are a family business and our customers are treated as an extension of our family. So please consider our invitation and become part of our family.
No job is TOO BIG or TOO SMALL, We Do ALL!
Contact us today to get started with your project.


text:
Shots fired into police officers' home as media and celebrities continue to demonize police
A manhunt is currently underway for two suspects who fired shots into the home of two police officers in Camden County, New Jersey shortly before midnight on September 15.
The officers were inside their home with their 10-day-old infant when six rounds of bullets hit their home. Although six of the bullets penetrated the exterior – two of which went right through the front door — the family was upstairs, and no one was injured by the gunfire.
Officials say the couple were targeted because they are police officers, although a specific motive has not been identified. The man and woman, who are married, have been working for the police department for four and two years, respectively, and were born and raised in Camden. They were both part of the department's community policing unit.
Camden County Police Chief Joseph Wysocki said: "I do know that this was a targeted attack against this residence and the officers inside." He said it is "very common knowledge" that the officers live there.
The FBI and other law enforcement agencies have joined in the investigation of the frightening incident. Police have already located the vehicle they believe the shooters were driving, a 1998 Honda Odyssey, and have appealed to the public to come forward with information about it.
The reward for information that leads to the arrest of the suspects has risen to $75,000. Officers believe there were three people in the car during the shooting, including two gunmen and a driver.
Camden County Freeholder Louis Cappelli said he told the police chief to "do whatever is necessary to stop any more violence against our officers immediately."
He also had harsh words for the perpetrators, saying: "This mindless evil conduct will not be tolerated."
"I want to share a very clear message to the scumbag thugs behind this senseless act. We're coming to get you and you will be prosecuted to the fullest extent of the law. If you think you can get away with these crimes under the cover of some unfortunate acts taking place in other parts of the nation, or under cover of some national movement, you are wrong," he added.
In another recent attack against police, two sheriff's deputies in Los Angeles were shot earlier his week in an ambush attack as they sat in the front seat of their patrol SUV at a metro station. The suspect can be seen in surveillance video approaching the vehicle from behind, walking over to the passenger side and firing a handgun through the window before running away.
One of the officers involved has been released from the hospital but has a long road ahead as he recovers from wounds to his arm and forehead. The other deputy, a 31-year-old woman who has a young child, is still in the hospital and was shot in the jaw. The suspect is believed to be a black male aged 28 to 30 who has yet to be apprehended; the reward has climbed to $675,000. More than $800,000 has already been donated toward the officers' medical care.
Anti-police sentiment being stoked by media and celebrities
As brazen as these attacks are, it is not terribly surprising to see a spike in violence against the police given how much the left-wing media and liberal celebrities have been demonizing all police and even encouraging violence against them while turning criminals into heroes. They are calling for defunding the police, but who do they plan to call when something bad happens to them?
The mainstream media is quick to report on cases involving white officers using physical restraint on black suspects despite this representing only a small fraction of incidents and celebrities are all too happy to tweet about it on the rare occasion that it does happen, but the silence when a white officer does something heroic is deafening.
6ABC.com
Tagged Under: anti-police, anti-police sentiment, Black Lives Matter, celebrities, crime, defund the police, hate, intolerance, left cult, mainstream media, Police, propaganda, violence
Seditious AOC tells Americans to take to the streets, "radicalize and fight" as Trump, GOP Senate consider Ginsburg's successor
DOJ reportedly considering bringing charges against Portland officials for not protecting citizens
"Protesters" in Philadelphia chase down and assault random citizens for being "Nazis"
BREAKING: DOJ declares Seattle, Portland and New York to be lawless anarchist zones, setting up federal arrests of Democrat mayors after the election
"Regular attendee" of anti-police demonstrations in Seattle arrested for arson
WaPo goes all-in with domestic terrorism, now serves as haven for Antifa propaganda
Far-left extremists using memes on social media to instigate violence: report
The riots: More questions than answers
09/21/2020 / By naturalnews
U-Haul trucks set ablaze by protesters owned by Black man who placed 'Black owned' sign outside. He's livid
Likely TIMELINE of events to take place from Sep. 20 to Jan. 20, covering vaccines, SCOTUS, Election Day, markets, terrorism and insurrection
Portland police stretched too thin and starting to crack under stress of renewed rioting, budget cuts
Kamala Harris praises the rioting and looting, calls it "marching" and states she has "great optimism"
Minneapolis residents "terrorized" by crime wave; police "nowhere to be seen" after defunding push
AG Barr drops massive truth bombs: Wants 'violent' rioters charged with sedition – liberals freaking out over Barr's comments on lockdowns, riots, prosecutors and media
Damage from riots across the US may cost insurance companies more than $1 billion
"Where are the police?" Anti-police Minneapolis City Council begs department to stop surging crime rate three months after voting to defund and abolish the police
Vandal beheads statue of Jesus in El Paso Cathedral for 'wrong skin color'
The NFL, NBA and MLB are promoting Black criminals as heroes and putting a target on law enforcement
Study finds that 95% of riots have links to Black Lives Matter


Download a custom recovery - you can download TWRP. Simply download the latest recovery file, named something like twrp-x.x.x-x-nicki.img.
With the device powered off, boot the device and press Volume Up when the notification light is pink.


A new website focused on empowering Idahoans to do just that is now available.
LiveBetterIdaho.org is a new and unique way for consumers to discover and connect to supports that can help them live healthier lives. By linking them to appropriate services, they can be empowered to make better choices and – we hope — move themselves and their families to independent, healthier lives.
Gov. C.L. "Butch" Otter spoke to the media Thursday morning assessing the 2015 legislative session, and addressed the child support bill that was tabled, SB 1067. Otter said he is working with lawmakers to find a solution.
"I think it's important that we understand the consequences of doing nothing," he said.
Idaho collects more than $200 million in child support payments a year, on average. The chart below is a point-in-time snapshot for March 2015. Organized by county, it shows the number of children involved in child support orders in Idaho, what percentage of the total county population those children represent, and the total of child support payments collected. The amount of child support received by each child varies.
Wage Withholding: The most important tool the state uses to collect child support payments from non-custodial parents who don't voluntarily make their payments is wage withholding. The increase in collections by wage withholding is due, in part, to improved accuracy, ease of paternity testing, and the new-hire reporting system. In FFY 2014, $105.8 million was collected using this tool, accounting for 61 percent of all the state's child support collections, as shown in the chart below.
A number of people are wondering which states have enacted the child support legislation that the Idaho House Judiciary, Rules and Administration committee tabled on Friday afternoon. Here is a map posted by the Uniform Law Commission. If you visit their website, you will find a complete list of states.
The Department of Health and Welfare's executive leadership team conferenced first thing this morning with Vicki Turetsky, commissioner for the federal Office of Child Support and Enforcement (OCSE). The topic— what will happen to the Idaho Child Support program after the Idaho Legislature's failure to approve a bill allowing the state to meet minimum federal program requirements.


Odisha Adarsha Vidyalaya Sangathan has successfully conducted the written examination for the 1544 vacancies available for different teaching posts. The test was held from 29 to 31 May for TGT, PGT, PET, Principal, Music, Art & Computer Teacher. Applicants who attended this exam are now looking for OAVS Answer key 2018 of Written Exam held in May 2018.
The solutions of written test will help the applicants to evaluate their performance attained in the written test. After the written exam, Odisha Adarsha Vidyalaya Sangathan Answer Key is shortly to be released at official portal. Candidates can download their set wise and subject wise from the official links mentioned below.
Recruitment is being conducted for 1544 teaching posts. The written exam for the post was scheduled across various exam centers. Now with the help of Question Paper Solutions, you can calculate your expected marks and cut offs. Candidates can calculate their scores section wise they can obtain in exam and can appear for the further selection process.
So stay in tuned with this web-page in order to get latest updates regarding OAVS 2018 Answer Key. With help of answer key you can also calculate expected cut off marks and can prepare yourself for the next round.


text:
Jn 10 Good Shepherd
<< THE GOOD SHEPHERD. >>
THE DIVINE LOVE.
1″I tell you the truth, the man who does not enter the sheep pen by the gate, but climbs in by some other way, is a thief and a robber. 2The man who enters by the gate is the shepherd of his sheep. 3The watchman opens the gate for him, and the sheep listen to his voice. He calls his own sheep by name and leads them out. 4When he has brought out all his own, he goes on ahead of them, and his sheep follow him because they know his voice. 5But they will never follow a stranger; in fact, they will run away from him because they do not recognize a stranger's voice." 6Jesus used this figure of speech, but they did not understand what he was telling them. 7Therefore Jesus said again, "I tell you the truth, I am the gate for the sheep. 8All who ever came before me were thieves and robbers, but the sheep did not listen to them. 9I am the gate; whoever enters through me will be saved.[a] He will come in and go out, and find pasture. 10The thief comes only to steal and kill and destroy; I have come that they may have life, and have it to the full. 11″I am the good shepherd. The good shepherd lays down his life for the sheep. 12The hired hand is not the shepherd who owns the sheep. So when he sees the wolf coming, he abandons the sheep and runs away. Then the wolf attacks the flock and scatters it. 13The man runs away because he is a hired hand and cares nothing for the sheep. 14″I am the good shepherd; I know my sheep and my sheep know me— 15just as the Father knows me and I know the Father—and I lay down my life for the sheep. 16I have other sheep that are not of this sheep pen. I must bring them also. They too will listen to my voice, and there shall be one flock and one shepherd. (JOHN X. r-16.)
THE SHEPHERD.
Our Lord is the Divine Shepherd of men. The Divine Love leads us; the Divine Wisdom teaches us; and the Divine Power protects us. And this trinity of Divine qualities we see in our blessed Lord, Jesus Christ, the one, only God of heaven and earth; one in Person, yet seen in different aspects and manifestations, as Creator, Redeemer and Regenerator; the one Divine Shepherd over the whole human race. In the Old Testament, He is made known as Jehovah. "Jehovah is my Shepherd: I shall not want." And, in the New Testament, Jesus declares, "I am the good Shepherd." Thus in this, and in many other instances, Jesus identifies Himself with Jehovah, the one, only God. "I and the Father are one." "He that hath seen Me, hath seen the Father." The coming of Jesus Christ was a fuller manifestation to men, of the Divine Life, in its three aspects, of Love, Wisdom and Power. Through Jesus Christ, as the Divine Shepherd, men are led into the heavenly sheep-fold, under the watchful care of the Divine Providence.
SHEEP.
In an exact sense, sheep represent the principle of charity, or love to the neighbor. In a general sense, sheep represent all the good principles of affection, in the human mind. Personally, the Lord's sheep are those who are open to receive the Lord's love and wisdom, and ready to embody these in their lives.
THE SHEEP-FOLD, ETC.
And the sheep-fold represents the Lord's Church, in heaven; and also on earth, so far as the Church on earth is sincere, and obedient to the Lord, Thus, the sheep-fold is the Lord's heavenly kingdom, including all persons who are in a heavenly condition, whether in the natural world or the spiritual world. Individually, our sheep-fold is in our own mind, when heavenly good and truth are there united in our regenerate life. In one sense, the sheep-fold is the celestial Church, in distinction from the spiritual Church, which is represented by a vineyard. The shepherd represents one who leads and teaches. A sincere leader and teacher is moved by a love of interior and spiritual life, and a love of helping others, to develop their spiritual life. The flock are those who are led and taught.
Men are taught by truth, and led by love. But, as men must know truth, before they can love it, or obey it, so truth stands as a door to spiritual life: and the knowledge of spiritual truth is the door, or door-way, through which we enter into spiritual life. "If thou wilt enter into life, keep the commandments." But a man must first learn the commandments, before he can keep them, And so, a knowledge of truth is the door through which a man is introduced to the life of truth.
The Lord, as the Divine Truth, is the Divine Door of the sheep-fold. To enter into the sheep-fold, through the door, is to know the Lord; to go to Him, by means of His truth; to acknowledge Him, in His Divine character; to believe in Him; to love Him; and to obey Him. Those who approach the Lord, in His Divine Humanity, open themselves to Him, and keep alive, in themselves, the principles of spiritual good and truth, represented by the sheep.
The Oriental sheep-fold was an enclosure, walled with stone, or fenced with reeds, and having a door-way, which could be closed at night, and through which the shepherd came, in the morning, to lead out his sheep. But a thief or a wolf would "climb up some other way."
THE PORTER.
The porter, or watchman, stationed at the door of the sheep-fold, represents our rational faculty, our thinking ability, which keeps watch over the door of our mind, and tests the character of the things which seek to enter into our affections and thoughts. If we love the Lord's good and true principles of life, and if we are trusting in the Divine Providence, the revealed truths of our Lord's Word are as doors to our minds. And, beside these known and accepted truths, our rational faculty stands, as a porter. Whatever enters into our minds by means of the door of acknowledged truth, is a shepherd; it is something that will lead and teach us in the way to heaven.
SOME OTHER WAY.
But all evil and false influences refuse to stand the test of the Divine Truth: they do not enter by the acknowledged door; but they try to "climb up some other way," to enter into our affections and thoughts in some improper way, as, for instance, through our sensuous passions and prejudices. Every thing that seeks to come to us otherwise than through the revealed truth, i. e., through what we know to be good, true and useful, is, spiritually, a thief and a robber, seeking to injure our souls. And whatever comes to us in "some other way," seeking to influence us through our tendencies to evil, (our pride, our anger, our contempt of others, or any other infernal passion,) we can no more spiritually afford to entertain and heed, than the sheep can afford to welcome thieves, robbers and wolves, into the sheep-fold. And if we would remember this fact, we could save ourselves a great amount of struggle against the insinuating influences of the hells.
Our Lord opens our inward minds, and enters into them, with His heavenly influences, by coming through the door of revealed and acknowledged truth, drawn from the Divine Word, We are, therefore, to expect Divine aid, and the supply of spiritual life, through the truths of the Lord's Word, and not from the many worldly and infernal influences, which seek to climb up some other way, into our minds, and lives. "If they speak not according to this Word, it is because there is no light in them. "
THE SHEPHERD AND HIS SHEEP.
In Oriental lands, the relation between the shepherd and the sheep is very intimate. Generally, the shepherd is the owner of the sheep, or one of the family of the owner. Pasturage is scattered, and has to be sought. The sheep often have to go a great distance for water. Wolves and other wild beasts are numerous and fierce. Thus, the sheep are used to depending upon the shepherd.
NAMING THE SHEEP, ETC.
The shepherd names his sheep, as we name our dogs, horses and cattle. And the sheep know their names, and know the voice of their shepherd. They have confidence in their shepherd; and they come at his call, and follow him, anywhere. So, the Lord's sheep have confidence in their Divine Shepherd. And they hear His voice; i. e., they recognizeand obey His truths. "He calleth His own sheep by name." A name is given to designate a certain person. But, originally, persons were given names according to their qualities, or traits of character, as is still done among our North American Indians, and other nations. Names, then, represent qualities, for which the names are given.
CALLING THE SHEEP.
The Lord, as our Shepherd, calls His own sheep by name, when, by means of His truth, He reveals to man certain qualities of spiritual life, which they need to attain and cultivate; and when He reveals to them their own states and qualities of spiritual life. The Lord, in His all-wise Providence, adapts His teaching and His leading to the exact conditions and qualities of each of His followers, at each step in the man's life. Spiritually, He always calls each of His sheep by name ; i. e., in such a way that the Divine leading is always exactly and momentarily adapted to the man's spiritual condition, and to his needed progress.
LEADING OUT AND PUTTING FORTH.
And thus "He leadeth them out," from the understanding and love of good and true principles, to their practical application to daily life. And when the Lord "putteth forth His own sheep, He goeth before them ;" i, e., He does not drive them, by compulsion, as swine have to be driven, but He leads them, as sheep are led. And He does this by His own example of the good life that He led before men. "Thus, they have the Lord always before them, in His example, as well as in His teaching.
FOLLOWING THE SHEPHERD.
And the sheep follow Him ;" i. e., being in the love of the Lord, and submitting their will to His, they keep His commandments, and abide in His love. They are protected by His Divine Providence. They follow Him in practical life. They know His voice ; i. e., they understand His truths. Those who love to obey the truth are brought into condition to understand the truth. "Ye shall know the truth, and the truth shall make you free." "If any man will do His will, he shall know of the doctrine, whether it be of God."
When you are hungry and thirsty, you know what you want ; and you recognize your food, when you see it. And you take it eagerly. No argument is necessary, to convince you of its character. So, spiritually, those" who hunger and thirst after righteousness … shall be filled," because they know what they want, and they recognize good and truth, when presented. They are open to heavenly principles, and immediately respond to them. They have an intuitive perception of the good quality of good, and of the truthfulness of truth: and this intuition is, to them, what instinct is to the beast, a guide to its food, and a warning against what is unsuited to its use.
The heart and understanding of the Lord's sheep respond to good and true principles, as their eyes respond to the light, and their ears to sounds. Their love of the Lord, and their trustful following of Him, keep them in the inward recognition of spiritual principles. What they know, they know not by mere argument, nor by their natural senses, but from their hearts, in the " self-evidencing reason of love." The Lord's spiritual sheep know the voice of a truth, because it teaches them to be like the Lord.
On one occasion, when Jesus taught, "the people were astonished at His doctrine; for He taught them as one having authority, and not as the scribes." The scribes taught doctrines, upheld by the authority of man, and of tradition. But Jesus taught truth, by its own authority, and in its own spiritual light. And those whose eyes were prepared to see, easily saw the light of truth, in the Gospel of Christ.
THE STRANGER.
The Lord's sheep will not follow a stranger; for, spiritually, a stranger is one who is, estranged from the Lord, and who is not a lover or a follower of the Lord. Abstractly, a stranger is a false principle, which is a stranger to the Divine Truth. Those who love and follow the Lord will not be led away by false persuasions and evil influences. They will shun and reject such influences. Their intuitive repugnance to evil and falsity will warn them of the presence of infernal influences.
THE REPRESENTATION.
It has sometimes been suggested that it was inappropriate to represent the Lord's followers by such a timid, defenceless animal as a sheep; and that it would be more natural to use, as a representative of good men, some more powerful, self-confident beast. But such a suggestion is made in ignorance of the nature of correspondence and symbolism. The proud, powerful, self-confident, fighting beast, feeling able to take care of itself, represents our selfish, unregenerate state of mind, when we do not feel the need of any Saviour. But the helplessness of the sheep, inducing him to seek a leader, fitly represents the regenerate man, who feels his own inability to save himself: and his need of a Divine Leader. And the gentle, docile, affectionate character of the sheep truly represents the changed character of the regenerate man.
The parable was spoken to the multitude, including some of the Pharisees: no wonder? then, that they did not understand it. And Jesus further taught them, He said plainly, "I am the door, of the sheep." As the Divine Truth, He is the door, leading to the Divine Love, which is the shepherd, and to the sheep-fold, which is His Church, and heaven.
THIEVES AND ROBBERS.
"All that ever carne before Me are thieves and robbers ." not literally, as to worldly times and persons. The Lord did not condemn all previous teachers and leaders. Spiritually speaking, all that ever came before the Lord, are all who put themselves before the Lord, in importance ; all who exalt themselves above the revealed truth of the Divine Word ; all who feel able to know truth from their own ability, and without revelation.
Speaking abstractly, all evil and false principles put themselves before the Lord, and exalt themselves above Him. These are, spiritually, thieves, claiming' truth as their own, and stealing It from the Lord. And they are robbers, claiming good as their own, and separating it from the Lord. No man can receive good and truth, as such, unless he receives them from the Lord, and as Divine things. Separated from the Lord, they lose their vitality, as an arm separated from the body.
FAITH IN THE LORD.
Sincere faith in the Divine character of the Lord, Jesus Christ, opens the mind to spiritual light, and enables the man to become spiritually intelligent. Without such faith a man lives in natural light, only, and does not rise to spiritual light. Hence, the acknowledgment of the Lord, Jesus Christ, as the, God of heaven and earth, is, truly, the entrance through the door, into spiritual life. "No man cometh to the Father but by Me ;'" i. e., no one can comprehend and approach the Divine Love, except by means of the Divine Truth which make" known the Divine character and personality. Through the Lord, men "enter in" to interior, spiritual life, and "go out" into practical natural life, led, taught, and protected, by the Divine Shepherd, and finding heavenly pasture, in the daily duties of active life. They "enter in" to the interior understanding of the Divine character, and "go out" into application of heavenly principles to practical deeds of daily conduct.
GIVING UP LIFE.
Jesus, as a good Shepherd, gave His life for the sheep, in the assumption and glorification of His Humanity : in the death of all that was born of Mary, and the conjunction of the Divine Human with the Divine, itself. In this, we have an example of our need to die, as to evil, that we may live, spiritually. False and evil principles, "thieves and robbers," come to men, to deprive them of all good and truth; but the Lord came, to give men more good and truth, and to save them from evil and falsity.
HIRELINGS.
In the letter of the parable, there is a comparison between the Lord, as the good Shepherd, and the leaders of the Jews, as evil shepherds, or hirelings. "He shall feed His flock, like a shepherd: He shall gather the lambs with His arms, and carry them in His bosom : and shall gently lead those that are with young." But a hireling is one who works for the hire, and not for the good that he can do. A good man, though he is properly paid for his work, loves to be useful. The pay is not the end in view, in his life, but only a means of doing good. So, a spiritual-minded man eats food, and properly enjoys it; but he does not live to eat, but, rather, eats that he may 'live, and be useful. A hireling is one who loves self and the world, and who works for selfish and worldly ends. With him, worldly gain comes first; but, with the good man, gain is the, servant, not the master.
The hireling does not own the sheep; i. e., he has no good principles adopted as his own principles of life, and embodied in his life. He cares nothing- for the safety of the sheep. Such a hireling is one who has some knowledge of principles, but no real interest in them. And so, when evils arise, in himself he does not resist these evils, but allows them, like wolves, to seize and to scatter whatever beginnings of good and true principles the Lord has taught him.
THE WOLF.
The wolf is the love of false principles, which seizes the good, and scatters the truths, from the worldly mind. Thus, the wolf is in the sinner's own heart: and when temptations arise, and evils and falses assail the mind, if the man is a hireling, who does not inwardly care for the spiritual sheep of good principles, he will not give up his selfish life, in defence of the spiritual sheep; but he will abandon the contest, and allow evil and false principles to rush in, and to destroy, whatever inclinations to good and truth the Lord had implanted in his mind.
KNOWING, AND BEING KNOWN.
The Lord knows His sheep, as His: they love Him, and abide in Him; and He gives them eternal life. But there were others, who boasted of their intimacy with the Lord: and yet, when the judgment carne, the Lord said to them, "I never knew you: depart from Me, ye that work iniquity." And the Lord says, I "am known of Mine ;" i. e., ,those who love the Lord, and follow Him in life, know Him as their Lord and Saviour. They require no argument, and no dogma of human authority.
They are like the Samaritans, who went out to see Jesus, at the call of the woman, but who afterwards said to the woman, "Now we believe, not because of thy saying; for we have heard Him, ourselves, and know that this is, indeed, the Christ, the Saviour of the world."
Worldly men argue about Christ, and dispute about His credentials; but spiritual men see and know Him, love Him, understand Him, and follow Him into the beatitudes of spiritual life. Truth appeals to the spirit of man. External miracles compel the wonder of the senses. But miracles do not convince a man of spiritual truth. In the open soul, there is an ability to know truth, as truth, which far transcends any appeal to the senses. To the spiritual man, there is nothing more evident than truth, itself: it needs no endorsement from the outside.
SIMPLICITY NEEDED.
The great need of men is simplicity of spirit, a condition of humble, loving, docile heart, following the Lord in the path of life, without self-will, without feverish excitement, without selfish ambition, without craving for .adventure : satisfied with the daily performance of uses, under the care of the Good Shepherd. As the Divine Father acknowledged the Humanity, and as the Humanity reciprocally acknowledged the Divine Father, "by becoming one with Him through glorification of the Humanity ; so the Lord, as the good Shepherd, acknowledges His sheep; and, in their measure' and degree, His sheep acknowledge Him, and become one with Him, in the regeneration.
THE OTHER FOLD.
In one sense, the Lord's sheep-fold are those who are in the Church; and His other sheep, not of this fold, are the Gentiles, not yet gathered into the Church, but yet to be instructed and led. In a more exact sense, the two folds are the kingdoms of the Lord, the celestial and the spiritual, which yet form one grand heaven. The spiritual heaven was formed by the Lord, at His coming in the flesh, when a judgment cleared the intermediate world of spirits, and a spiritual heaven was formed of many who had long been waiting in the world of spirits. And thus the Lord came to gather those who were not of the celestial sheep-fold, but who could then be formed into a spiritual heaven, under the one Shepherd, in whose sight the whole heaven is one grand sheep-fold. "
TAKING UP LIFE.
Jesus laid down His life, that He might take it, again. So, In the regeneration, we lay down our natural, selfish, worldly life, that we may take up a new, spiritual, heavenly life. "Whosoever will save his life, shall lose it: and whosoever will lose his life for My sake, shall find
It. And, Indeed, how often it is the case, that we draw nearer to our Lord, and trust in Him more implicitly, in times of trial and sorrow, than in hours of apparent prosperity. We can almost feel His great, yet tender, arm, lifting us over the hardest places in the path. Often, with us, as with the sheep in Palestine, the greenest pasture lies upon the southern ridges of the steep and rocky hills. Strength, courage, and endurance are needed, to reach them. But the Divine Shepherd leads us according to our strength, and gives us all the strength that we will exert ourselves to use.
NT PARABLES
Mt 1 House on Rock
Lk 5 Old – New Cloth
Mt 11 Children – Markets
Mt 12 The Sower
Mt 13 Tares and Wheat
Mt 13 Mustard Seed
Mt 13 The Leaven
Mt 13 Hidden Treasure
Mt 13 Seeking Pearls
Mt 13 The Draw-Net
Mt 13 Instructed Scribe
Mt 18 Unmerciful Servant
Mt 20 Laborers Vineyard
Mt 21 The Two Sons
Mt 21 Wicked Farmers
Mt 22 The King's Son
Mt 24 The Fig Tree
Mt 25 The Ten Virgins
Mt 25 The Talents
Mk 4 Growing Secretly
Lk 6 Blind Leading Blind
Lk 7 The Two Debtors
Lk 10 Good Samaritan
Lk 11 Importunate Friend
Lk 12 The Rich Fool
Lk 12 Loins Girded
Lk 13 Barren Fig Tree
Lk 14 Lowest Seats
Lk 14 The Excuses
Lk 14 Building a Tower
Lk 15 The Lost Sheep
Lk 15 Lost Silver Piece
Lk 15 The Prodigal Son
Lk 16 Unjust Steward
Lk 16 Rich and Lazarus
Lk 17 Unprofitable Servant
Lk 18 The Unjust Judge
Lk 18 Pharisee – Publican
Jn 15 Vine and Branches


text: A data type for transfinite numbers.

redpajama_set_name: RedPajamaGithub


text:
White House contest casts shadow over mega-deal
Presidential politics are casting a shadow over the biggest media acquisition of 2016. The outcome of the White House race could help determine the fate of the proposed $85 billion sale of Time Warner to telecommunications behemoth AT&T, an unusual situation for a massive sale. "It's such an interesting thing about this deal, is the fact that it was announced when it was announced," said Craig Aaron, president of Free Press, which argues the deal would be bad for consumers. "I think this would be a highly controversial deal whenever it happened, but the fact that it's happening two weeks out from the election and will be decided by … appointees who nobody knows who they are yet, makes this a much more political fight than maybe it would have been if it had happened at another time." Neither of the presidential hopefuls has spoken kindly of the proposal.


Holm is 50 km Northwest of Sundsvall. From Sundsvall you go about one mil on the way 86 and turn off at Kovland towards Holm on the road 320. Roads also connect Holm countryside from towns Liden, Stöde, Torpshammar and Kälarne. Type your address below for directions to the Holm (Church).
Here you will also find a collection of a variety of maps of Holm.
Coordinates for you to navigate with GPS / navigator.
Address: Anund Farm 180, Postort: Liden.


In Dubai, Severg is practically getting involved in the routine activities or major operations conducted by people for finding the probabilities of getting a flaw or a defect in the work processes. This task is eminently taken up by our proficient private investigators or detectives who are attained certain level in the investigative market where we are capable of providing the best facilities of having the investigations and detective services to improve the system by avoiding all causes which can responsible for degrading over all mechanism by inducing dangerous activities in the organization. Severg is one of its own kind in Dubai for having best investigator who can be best used for uprooting various unhealthy and dreaded causes in the very first attempt by giving the way to have the perfect application of prestigious private investigation services for speedy results and well desired solution of major risks coming up in the form of variety of frauds and corruptions in prime sector.
Our private investigators are making Severg feel proud of their intelligent works, dedicated efforts and consistent positive results obtained in making the risk free environment by reducing the level of risks usually persist in the organizations. The knowledgeable professionals Severg are striving to eliminate the undetectable flaws and defect through effective private investigations. We have the niche to offer the best protection to secure the organizations at all level.
With numerous featuring services, today, Severg is going limitlessly its objective to look after security aspects of various organizations in different parts of Dubai including other cities like Abu Dhabi and Sharjah.
Bugging and Tapping : This type of highly illegal and defamed activities always avoided by our lawful private investigators who are working for Severg in the territory of Dubai.


The following course in Introduction to science Skills is provided in its entirety by Atlantic International University's "Open Access Initiative" which strives to make knowledge and education readily available to those seeking advancement regardless of their socio-economic situation, location or other previously limiting factors. The University's Open Courses are free and do not require any purchase or registration, they are open to the public.
Science is not merely a collection of facts, concepts, and useful ideas about nature, or even the systematic investigation of nature, although both are common definitions of science. Science is a method of investigating nature--a way of knowing about nature--that discovers reliable knowledge about it. In other words, science is a method of discovering reliable knowledge about nature. There are other methods of discovering and learning knowledge about nature (these other knowledge methods or systems will be discussed below in contradistinction to science), but science is the only method that results in the acquisition of reliable knowledge.
The professional development of science teachers requires the learning of fundamental scientific contents; the integration of knowledge's from science, education and child studies and requires also the application of these knowledge to science teaching (Radford, 1998; Briscoe, Peters & O'Brien, 1993; National Academy of Sciences, 1996). Professional development should occur through inquiry methods and perspectives, that is teachers should first experiment the methods and activities that they are expected to use in their classrooms, in an environment of support and reflection of their experiences.
The purpose of science education is no longer simply to train that tiny fraction of the population who will become the next generation of scientists. We need a more scientifically literate populace to address the global challenges that humanity now faces and that only science can explain and possibly mitigate, such as global warming, as well as to make wise decisions, informed by scientific understanding, about issues such as genetic modification. Moreover, the modern economy is largely based on science and technology, and for that economy to thrive and for individuals within it to be successful; we need technically literate citizens with complex problem-solving skills.
Teaching resources In the teacher training context, a teachers' performance adequate to a given pedagogic practice requires the acquisition of: (a) recognition rules to distinguish the specificity of the context of that practice; (b) passive realization rules to select the appropriate meanings to that on text; (c) active realization rules to implement in the classroom that pedagogic practice. Teachers' adequate performance requires also to have socio-affective dispositions towards the implementation of that practice. Science is an inspiring process of discovery that helps satisfy the natural curiosity with which we are all born. Unfortunately, traditional instruction that misrepresents science as a body of facts to be memorized and the process of science as a rigid 5-step procedure can deaden students' spirit of inquiry.
To understand what science is, just look around you. What do you see? Perhaps, your hand on the mouse, a computer screen, papers, ballpoint pens, the family cat, the sun shining through the window …. Science is, in one sense, our knowledge of all that — all the stuff that is in the universe: from the tiniest subatomic particles in a single atom of the metal in your computer's circuits, to the nuclear reactions that formed the immense ball of gas that is our sun, to the complex chemical interactions and electrical fluctuations within your own body that allow you to read and understand these words. But just as importantly, science is also a reliable process by which we learn about all that stuff in the universe. However, science is different from many other ways of learning because of the way it is done. Science relies on testing ideas withevidence gathered from the natural world.
The confidence of scientists arises from their knowing what they are doing and from their ability to say what science is. Science is progressive and exact. It is progressive in that it is always being revised, with new findings replacing what was once held to be knowledge. To be sure, what is held to be knowledge now will change, perhaps very soon. Is physics about atoms? No, today it is about the distance between atoms. Strict science is today's science; there is no reason for scientists to study the past of their discipline, the history of science. That field is part of non-science, the history department, not of science. If Galileo were to return today, he would accept our science as improved, as more exact. "Exact" means "leaves no room for doubt." What is most exact? Mathematics; so science today is mathematical.
Erasmus Darwin (1731-1802; grandfather of Charles Darwin) a British physician and poet in the late 1700's, proposed that life had changed over time, although he did not present a mechanism. Georges-Louis Leclerc, Comte de Buffon (pronounced Bu-fone; 1707-1788) in the middle to late 1700's proposed that species could change. This was a major break from earlier concepts that species were created by a perfect creator and therefore could not change because they were perfect, etc.
Swedish botanist Carl Linne (more popularly known as Linneus, after the common practice of the day which was to latinize names of learned men), attempted to pigeon-hole all known species of his time (1753) into immutable categories.
The student population in the U.S. is increasingly more diverse racially and ethnically. The U.S Census collects data on race based on demographic groups of non-Hispanic White, Hispanic, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander. Although the National Assessment of Educational Progress (NAEP) Science scores have improved in recent years, significant achievement gaps by racial subgroups persist. Current policies address these shortfalls by implementing guidelines for tracking the progress of underrepresented groups of students in science and by calling to address science achievement gaps.