text:
ERJ Early View
ERS Publications
European Respiratory Journal
ERJ Open Research
European Respiratory Review
ERS Books
ERS publications home
A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation
M. Confalonieri, G. Garuti, M. S. Cattaruzza, J. F. Osborn, M. Antonelli, G. Conti, M. Kodric, O. Resta, S. Marchese, C. Gregoretti, A. Rossi
European Respiratory Journal 2005 25: 348-355; DOI: 10.1183/09031936.05.00085304
M. Confalonieri
G. Garuti
M. S. Cattaruzza
J. F. Osborn
M. Antonelli
G. Conti
M. Kodric
O. Resta
S. Marchese
C. Gregoretti
A. Rossi
Knowing the likelihood of failure of noninvasive positive pressure ventilation (NPPV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD) could indicate the best choice between NPPV and endotracheal intubation instituted earlier. For this purpose, two risk charts were designed (at admission and after 2 h of NPPV) that included all relevant measurable clinical prognostic indicators derived from a population representing the patients seen routinely in clinical practice.
Risk stratification of NPPV failure was assessed in 1,033 consecutive patients admitted to experienced hospital units, including two intensive care units, six respiratory intermediate care units, and five general wards. NPPV was successful in 797 patients.
Patients with a Glasgow Coma Score <11, acute physiology and chronic health evaluation (APACHE) II ≥29, respiratory rate ≥30 breaths·min−1 and pH at admission <7.25 have a predicted risk of failure >70%. A pH <7.25 after 2 h greatly increases the risk (>90%). The risk charts were validated on an independent group of 145 consecutive COPD patients treated with NPPV due to an acute ventilatory failure episode. To identify patients with a probability of failure >50%, the sensitivity and specificity were 33% and 96.7% on admission and 52.9% and 94.1% after 2 h of NPPV, respectively.
The prediction chart, based on data from the current study, can function as a simple tool to predict the risk of failure of noninvasive positive pressure ventilation and thus improve clinical management of patients tailoring medical intervention.
endotracheal intubation
noninvasive ventilation
Noninvasive positive pressure ventilation (NPPV), in patients with exacerbations of chronic obstructive pulmonary disease (COPD) and respiratory acidosis, reduces the intubation rate and mortality 1–9. Operated by well trained teams, NPPV is effective and safe in both intensive care settings 10 and general respiratory wards 8. A randomised, clinical trial showed that NPPV also reduces mortality in COPD patients in the intensive care unit (ICU) within the inclusion criteria for intubation 6. Nevertheless, two recent consensus guidelines on NPPV in acute respiratory failure (ARF) recommend that NPPV should not be used as a substitute for endotracheal intubation and invasive ventilation when the latter is clearly more appropriate 11, 12.
The likelihood of failure of NPPV is crucial in deciding if and when to apply this ventilatory technique. However, attempts to predict the success of NPPV have only been made in single-centre studies that included a limited number of patients 13–15. Furthermore, results from randomised, controlled studies could be affected significantly by the research setting, e.g. strict selection criteria of patients or a unique care location. This limits the possibility of generalising the results to the daily clinical practice of general hospitals 16.
The purpose of the current study was to assess the risk of NPPV failure in a large unselected population admitted to different hospital units with expertise in the application of NPPV and to build a risk chart of failure of NPPV to be used in hospitals.
From December 1998 to March 2000 prospective data was collected from 1,033 consecutive patients affected by COPD exacerbation and respiratory acidosis that were treated by NPPV in addition to standard medical therapy (oxygen supplementation, systemic corticosteroids, inhaled bronchodilators, antibiotics, and diuretics if needed). These patients were admitted to two ICU, five general wards and six respiratory intermediate intensive care units (RIICU) where NPPV is the first-line intervention for such patients 17. The admission criteria to different units were based on the need for an appropriate level of care, but the personnel in each unit were well trained in the use of NPPV, with ≥3 yrs experience. The various units used different types of ventilators, either intensive care ventilators (Servo 300; Siemens Elema, Solna, Sweden. Puritan Bennet 7200; Puritain Bennett Co., Overland Park KS, USA) or less sophisticated ventilators (BiPAP Respironics; Respironics Inc., Murrysville, PA, USA. O'nyx Mallinckrodt; Mallinckrodt Inc, Minneapolis, MN, USA. Helia Saem; Saime, Savigny-le-Temple, France) via face and/or nasal mask. Every patient who received NPPV because of hypercapnic respiratory failure and respiratory acidosis due to exacerbation of COPD was included in the current observational study. Post-operative patients and patients receiving NPPV for weaning were excluded. The definition of COPD exacerbation was in accordance with that of the American Thoracic Society 18. NPPV failure was defined as the need for endotracheal intubation. Pre-determined criteria for endotracheal intubation included: 1) worsening of pH and carbon dioxide tension in arterial blood (Pa,CO2) in spite of correct NPPV administration (e.g. pH ≤0.04 and Pa,CO2≥0.8 kPa (≥6 mmHg)); 2) the need to protect the airways (coma or seizure disorders) or to manage copious secretions; 3) haemodynamic instability (heart rate <50 beats·min−1 with loss of alertness, and/or systolic blood pressure <70 mmHg); and 4) agitation and inability to tolerate the mask.
The following data were collected for every patient. 1) General demographic information (age, sex, weight and height) and clinical data. Severity of illness was assessed by acute physiology and chronic health evaluation (APACHE) II score 19, and neurological status was assessed by the Glasgow Coma Scale (GCS) 20. 2) Data relative to the institution of NPPV, including cause of exacerbation, arterial blood gases (before beginning NPPV, after 2 h and at discharge), respiratory rate (RR), cardiac frequency, length of stay in hospital, and total hours of ventilation. 3) Data on comorbidities, previous use of home mechanical ventilation and long-term oxygen therapy.
Variable definition and statistical analysis
The outcome variable was defined as failure of NPPV due to invasive ventilation or death.
After descriptive analysis, univariate analysis was performed using the unpaired t-test to examine differences in continuous variables. Multivariable logistic regression was used to analyse the independent effect of each variable on the outcome (treatment failure) and the strategy used to determine which variables should be included in the multivariable analysis was based on whether the variable was of direct interest or merely a confounder. Variables of interest were included, whilst confounders that showed little or no effect, or variables related to a very small number of patients, were eliminated. After the elimination of these confounders, factors of interest were eliminated if their effect was not statistically significant at the 5% level (except pH between 7.25–7.29 at admission due to the interest of pneumologists for this category of pH and to allow comparability between the two charts). This strategy may, of course, be considered rather arbitrary, as statistical significance at the 5% level does not necessarily imply that the variable will be a useful predictor. Also, variables such as body weight, which for many patients was not measured, were excluded as these missing values reduce the effective sample size, and, if they were not available for a new patient, it would not help in the prediction of the outcome of treatment. However, this procedure was considered more efficient in the search for true prognostic variables than an automatic step up or step down elimination procedure. All tests and p-values are two-tailed.
Two charts of failure risk were built from the final predictive models obtained using logistic regression; they refer to the proportion predicted to fail with NPPV treatment at admission and after 2 h of NPPV. The proportions predicted to fail were calculated using the odds ratios (OR) derived from the models. The predicted risks of failure were graphically depicted in risk charts with changing colours showing the increasing level of risk, similar to the risk charts recently proposed by the European Societies of Cardiovascular Disease Prevention 21–25. To graphically graduate risk intensity, four different colours were used according to the quartile of predicted risk probabilities. The aim was for the predicted risk of failure to be used as a rule to decide whether or not to intubate. To explore this possibility, arbitrary probabilities of failure equal to 25%, 50% and 75% were selected as possible cut-off values and sensitivity, specificity and percentage of correctly classified patients were calculated for each cut-off value.
The chart of risk for failure of NPPV was evaluated in an independent sample of 145 consecutive patients admitted during a 3-month period to three units (one general ward, one RIICU, and one ICU) to be treated with NPPV, due to an acute episode of COPD exacerbation.
Accuracy and generalisability
Accuracy, defined as the degree to which predictions match outcomes, and generalisability, defined as the ability to provide accurate predictions in different samples of patients 26, represent two important aspects of prognostic assessment and are essential if prognostic evaluation is aimed to improve clinical management of patients. Inaccuracy can be attributable either to errors in calibration (the predicted probabilities may result in a too high or too low) or to errors in discrimination (relative ranking of individuals may be out of order).
Concerning accuracy, the calibration of the model was assessed by evaluating expected to observed outcomes across deciles of risk, and discrimination was measured as the area under the receiver operating characteristic (ROC) curve (C statistic) 27.
Concerning generalisability, the predictive performance of the model was assessed through external validation, using an independent sample and comparing expected to observed outcomes across deciles of risk, and in totals and measuring the area under the ROC curve 27.
A total of 1,033 patients were recruited in the 13 centres. All the patients were treated with NPPV for the management of ARF due to COPD exacerbation. The main demographic and physiological characteristics at the start of NPPV are shown in table 1⇓.
Table. 1—
1 Main characteristics of patients at the start of noninvasive positive pressure ventilation
Table 2⇓ summarises the outcome data in the study population. NPPV was performed successfully in 797 patients (77.1%) until the normalisation of arterial blood gases. Among the 236 patients who failed, 185 patients were intubated (17.9% of the total and 78.4% of those for whom NPPV failed) and 51 died without intubation due to a previous "do-not-intubate" order. Among the 185 intubated patients, 94 patients successfully completed the treatment and 91 patients died. In total, 142 patients died (13.7% of the total and 60.2% of those for whom NPPV had failed). The intubation rates varied among the centres from 0 (zero intubated out of 72) to 72.2% (39 intubated out of 54). However, the rates were highest in the ICU at 50% and lower in general wards (13.6%) and in RIICU (15.7%).
2 Patient outcome(all units)
Table 3⇓ shows the means of variables which may be associated with a successful outcome. Successful patients were younger, less severe cases and had better values of Pa,CO2, pH, RR, and oxygen arterial tension/inspiratory oxygen fraction.
3 Univariate comparison between patients that succeeded or failed after treatment with noninvasive positive pressure ventilation
Table 4⇓ shows the final multivariable models including all the statistically significant predictors of NPPV failure. The variables measured on admission that were found to significantly increase the probability of NPPV failure were: APACHE II score ≥29 (OR = 3.30, p<0.001), GCS between 12–14 (OR = 2.29, p<0.001) or GCS ≤11 (OR = 4.40, p<0.001), pH <7.25 (OR = 1.97 p<0.05), and RR between 30–34 breaths·min−1 (OR = 1.83, p<0.05) or >35 breaths·min−1 (OR = 2.66, p<0.001). To allow comparison between admission and after 2 h, it was only possible to examine 594 patients out of 1,033 due to missing values, either for early failure or a lack of blood gas assessment. After 2 h of NPPV, the main factor influencing the outcome was the pH value: if pH <7.25 the OR for failure is 21.02 (p<0.0001), whereas if pH after 2 h is between 7.25–7.30, the OR is 2.92 (p<0.005). Also, all the other variables remained statistically significant: APACHE II score ≥29 (OR = 4.79, p<0.001), GCS between 12–14 (OR = 1.93, p<0.05) or GCS ≤11 (OR = 5.16, p<0.001), RR between 30–34 breaths·min−1 (OR = 2.67, p<0.001) or >35 breaths·min−1 (OR = 4.95, p<0.001). These models were then used to predict the risk of NPPV failure. Accuracy of the predictions was good as there were no statistically significant differences between expected and observed failures when compared across deciles of risk (at admission: Chi-squared = 3.46, degrees of freedom (dof) = 8, p = 0.9023; after 2 h: Chi-squared = 1.33, dof = 9, p = 0.9982). The final models had a high predictive capability, as illustrated by the values of the C statistic: 0.81 at admission (95% confidence interval (CI): 0.78– 0.84) and 0.88 after 2 h (95% CI: 0.85–0.90). The C statistic, which is equal to the area under the ROC curve, is a measure of the ability of the model to discriminate between patients who failed or succeeded with the NPPV treatment. The comparison of the two ROC curves was statistically significant (p<0.001), implying that the ROC curve after 2 h of NPPV is more efficient for prediction (fig. 1⇓).
Receiver operating characteristic curves at admission (–––) and after 2 h (- - -) of noninvasive positive pressure ventilation. ═: line corresponds to a test which is useless as a discriminator between successes and failures.
4 Logistic regression model used to build the risk chart
The risk chart at admission (fig. 2⇓) shows, in the top right corner, the lowest predicted probabilities of NPPV failing. These probabilities increase moving across the table and reach the highest peak in the bottom left corner. In detail, patients with pH >7.30, and APACHE II <29 have the lowest predicted probabilities of NPPV failing (∼10%), probabilities which increase when RR increases and GCS decreases. In contrast, patients with pH <7.25, APACHE II ≥29 and GCS <11 have a predicted risk of failure >70%.
Failure risk chart of noninvasive positive pressure ventilation at admission (the values in the table correspond to the percentage of patients who fail in each category). ⇓: 0–24%; ⇓: 25–49%; ⇓: 50–74%; ⇓: 75–100%. RR: respiratory rate; APACHE: acute physiology and chronic health evaluation II score; GCS: Glasgow Coma Scale.
The risk chart after 2 h of NPPV is interpreted similarly (fig. 3⇓), but the predicted percentages of failure increase and are ∼90% when pH is between 7.25–7.29, APACHE II is ≥29 and GCS ≥11. If pH is <7.25 after 2 h of ventilation, this greatly increases the risk of failure, especially if APACHE II is ≥29.
Failure risk chart of noninvasive positive pressure ventilation after 2 h (the values in the table correspond to the percentage of patients who fail in each category). ⇓: 0–24%; ⇓: 25–49%; ⇓: 50–74%; ⇓: 75–100%. RR: respiratory rate; APACHE: acute physiology and chronic health evaluation II score; GCS: Glasgow Coma Scale.
The generalisability of these models was assessed through an external validation using an independent sample of 145 patients, and the results were encouraging. There were no statistically significant differences between expected and observed failures when compared across deciles of risk and in totals at admission (Chi-squared = 2.96, dof = 8, p = 0.9371) and after 2 h (Chi-squared = 3.53, dof = 9, p = 0.9397), and the C statistic was 0.71 at admission (95% CI: 0.63–0.79) and 0.83 after 2 h (95% CI: 0.76–0.89). Again, the comparison of the two ROC curves was statistically significant (p<0.001, fig. 4⇓).
Receiver operating characteristic curves at admission (–––) and after 2 h (- - -) of noninvasive positive pressure ventilation using the predicted failure percentages of the risk charts, applied to the 145 patients that were prospectively collected (independent sample). ═: line corresponds to a test which is useless as a discriminator between successes and failures.
To explore the possibility of using the predicted risk of failure as a rule to decide whether or not to intubate, the following probability of failure was arbitrarily chosen: 25%, 50% and 75% as possible cut-off values and the corresponding scenarios are illustrated in table 5⇓. Sensitivity decreases when risk of failure increases, whilst specificity increases when risk of failure increases. The percentage of patients correctly classified is quite good and reaches its maximum at a cut-off value of 50% (82 and 85%, respectively at admission and after 2 h).
Prediction of success/failure of NPPV in the "real world"
The present study evaluated a large unselected group of patients with acute exacerbation of COPD and respiratory acidosis treated with noninvasive ventilation in different care settings (ICUs, respiratory intermediate units and general wards; all were experienced care settings). The current authors used these data to assess the risk of NPPV failure and built two risk charts for admission and after 2 h of ventilation. These charts could be used to determine the possibility of failure or success of NPPV in patients with acute decompensate COPD and to help the clinical decision-making process. In particular, given that the Gold Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines 28 suggested an initial trial of NPPV for most patients anyway, the decision to continue or not continue with NPPV can be greatly helped by the risk chart of failure tailored after 2 h of noninvasive ventilation.
The mortality rate in the current study is similar to that observed in the most quoted controlled trials on NPPV in carefully selected patients with acute exacerbation of COPD 1–3, 5. The present study showed also that outside a specialised research setting, in the everyday clinical environment, NPPV can be effectively used in all COPD patients, such as those with pneumonia or with a lower GCS who might otherwise be excluded in a restricted clinical trial.
A series of randomised trials on noninvasive ventilation in acute exacerbations of COPD was published showing the effectiveness of NPPV, but in single ward settings. Nevertheless, the possibility to predict at hospital admission the chance of success of NPPV in patients with exacerbation of COPD should be based on a patient population with a variable degree of severity of illness. Anton et al. 15 studied only 44 patients in a single centre and derived a regression equation using six parameters, including the baseline forced expiratory volume in one second and Pa,CO2 in a stable condition, that may not be available at all or not obtainable from older records at the time of admission. In contrast to Anton et al. 15, the present authors preferred not to use change variables as they are more likely to indicate the rapidity with which the patient improves (and consequently the length of stay in the hospital) rather than the failure/success of NPPV. Moreover, given that, in practice, the two values are often not available for every patient, the inclusion of changes in the risk chart would have reduced its usefulness for prediction, as well as increasing the sampling error due to the reduction in sample size. Indeed, there was already a reduction in sample size from admission to 2 h in the present study, and to have included the changes in the levels would have caused the sample size at 2 h to have been even further reduced.
Data from a multicentre study performed in British respiratory general wards showed that if pH and/or Pa,CO2 improved after 1–4 h, successful NPPV was probable 9.
In the large population of unselected patients in the present study, on admission, severity of illness and neurological impairment, respectively (assessed by APACHE II score and GCS), were found to influence significantly the probability of NPPV failure together with RR and pH. Clear differences were found between the patients who succeeded and those who failed, with respect to the predictor variables observed at admission and after 2 h of treatment. In particular, after 2 h of NPPV, the main factor influencing the outcome was the pH value. Since pH seems to be a very important variable in predicting failure of NPPV and there is much discussion about which is the correct cut off to choose, the current authors evaluated in both models a pH <7.25 and a pH ≥7.25 but <7.30, even if the latter was not statistically significant at admission. However, given that the decision to intubate is based on clinical judgement, and this judgement is also probably based on the values of predictor variables, there is a danger of falling into a circular argument. For example, patients with pH <7.2 tend to be judged to be in need of intubation and, therefore, pH <7.2 significantly predicts intubation. However, in the current analysis the cut-off values of the predictor variables were decided a priori, which should reduce this effect.
The presence of pneumonia, at admission and after 2 h, did not significantly influence the probability of NPPV failure in the patients of the present study. Ambrosino et al. 13 reported a high failure rate in nine COPD patients with pneumonia in a retrospective single centre study, but this was not confirmed by either a recent meta-analysis 8 or a prospective, randomised controlled study on NPPV in community-acquired pneumonia 29. In agreement with the current study, previous studies have reported that severity of illness scores 2, 14, 30 and pH 1, 2, 5, 31, 32 at enrolment are independent risk factors for NPPV failure in patients with exacerbations of COPD. A reduction in RR with NPPV has been shown in a number of studies, with larger falls generally being associated with a successful outcome 2, 3, 13, 14. Clearly, it is not only clinical status that can improve the outcome of NPPV e.g. intolerance of the mask can lead to failure of NPPV 10. However, this cannot be predicted for individual patients before starting NPPV; the patient should try NPPV for a minimum of 1–2 h, adjusting the mask and changing the interface. It should be noted that the present study population included a fairly high percentage of COPD patients, mechanically ventilated at home. This is more typical for Italy than other European Countries, and it could have some impact on the generalisability of results as these patients are "experts" at NPPV.
Applicability of predictive risk charts
The charts of risk for NPPV failure showed a good generalisability assessed on an independent sample of patients with acute exacerbation of COPD. Calculation of the area under the ROC curves showed a high accuracy of the prediction, and the rate of the patients correctly classified is >75% at each cut-off value arbitrarily chosen. Since prediction improves after 2 h of NPPV and the GOLD guidelines suggest an initial trial of NPPV for most patients anyway, the decision to continue or not continue with NPPV can be greatly helped by a risk chart of failure tailored after 2 h of noninvasive ventilation. This discussion should also focus on which cut-off value is the best choice i.e. above which risk of failure it is suggested to intubate. At one extreme, the risk of failure can be considered to be ≥0%, which implies that all the patients will fail with NPPV treatment and will be intubated, with a sensitivity of 100% and a specificity of 0%. At the other extreme, the risk of failure can be considered to be equal to 100%, which implies that all the patients will succeed with NPPV treatment and nobody will be intubated, with a sensitivity of 0% and a specificity of 100%. Clearly, these two options are only hypothetical; more realistic ones are depicted in table 5⇓. The risk of failure equal to 25% appears as a good option, as sensitivity and specificity are both at high levels, particularly after 2 h. However, a risk of failure equal to 25% can be considered as a low risk and several people will be indicated for intubation without really needing it (false positive). If the risk of failure of NPPV equals 75%, fewer people will be indicated for intubation, but some people who really needed it could be missed (false negative). Thus, perhaps a risk of failure equal to 50% could be a useful compromise for whoever wants to start using the predictive chart of risk, keeping in mind that this cut-off value could be changed if clinical experience suggests it.
Furthermore, it would be interesting to assess if both risk charts (admission and after 2 h) are useful in the clinical practice. In this case, the risk charts will be used consecutively, which will maximise specificity, but lower sensitivity. One ends up surer that positive test results represent failure of NPPV, but there is an increased risk of missing people who really need intubation.
Indeed, the GOLD guidelines suggest trying NPPV initially on all patients and only after 2 h of NPPV can a decision then be made whether to continue or not. In this case, only the risk chart of failure tailored after 2 h of noninvasive ventilation can be used, but it should greatly help the decision.
The efficacy of noninvasive positive pressure ventilation in acute exacerbation of chronic obstructive pulmonary disease is so well documented that international guidelines 28 recommend it as the first choice treatment of acute respiratory failure with respiratory acidosis. Nevertheless, given that noninvasive positive pressure ventilation is used in a variety of care settings, it may be important to know the likelihood of failure to decide upon the best choice between noninvasive positive pressure ventilation and endotracheal intubation instituted earlier. The prediction charts are based on data collected by the present authors and take into consideration all relevant clinical prognostic indicators and are derived from a population representing the patients seen routinely in clinical practice. Thus, the current authors think they could greatly help the decision on clinical management of the patient. Using the chart, it is possible to predict "a priori" the probability of noninvasive positive pressure ventilation failure and reduce the useless and prolonged use of noninvasive positive pressure ventilation in patients with respiratory acidosis due to chronic obstructive pulmonary disease exacerbation.
The authors would like to thank the Eleonora Lorillard Spencer Cenci Foundation for its contribution to the research.
The following physicians participated in the Italian NPPV study group: A. Bellone, R. Della Porta, A. LoCoco, M. Demsar, G. Gadaleta, M. Moretti, P. Parigi, G. Pinelli, M. Piattella, A. Potena, A. Rossi, F. Turati, A. Vianello, M. Vitacca.
Received July 19, 2004.
Accepted November 8, 2004.
© ERS Journals Ltd
Bott J, Carroll MP, Conway JH, et al. Randomized controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease. Lancet 1993;341:1555–1557.
Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;333:817–822.
Kramer N, Meyer TJ, Meharg J, Cece RD, Hill NS. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 1995;151:1799–1806.
Celikel T, Sungur M, Ceyhan B, Karakurt S. Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure. Chest 1998;114:1636–1642.
Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet 2000;355:1931–1935.
Conti G, Antonelli M, Navalesi P, et al. Noninvasive versus conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med 2002;28:1701–1707.
Peter JV, Moran JL, Phillips-Hughes J, Warn D. Noninvasive ventilation in acute respiratory failure. A meta-analysis update. Crit Care Med 2002;30:555–562.
Lightowler JV, Wedzicha JA, Elliott MW, Ram FSF. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ 2003;326:185–190.
Plant PK, Owen JL, Elliott MW. Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome. Thorax 2001;56:708–712.
Carlucci A, Richard JC, Wysocki M, Lepage E, Brochard L. Noninvasive versus conventional mechanical ventilation. An epidemiologic survey. Am J Respir Crit Care Med 2001;163:874–880.
American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine and Societè de Reanimation de Langue Francaise. International Consensus Conference in Intensive Care Medicine: positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 2001;163:281–291.
British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:192–211.
Ambrosino N, Foglio K, Rubini F, Clini E, Nava S, Vitacca M. Noninvasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax 1995;50:755–757.
Soo Hoo GW, Santiago S, Williams J. Nasal mechanical ventilation for hypercapnic respiratory failure in chronic obstructive pulmonary disease: determinants for success and failure. Crit Care Med 1994;27:417–434.
Anton A, Guell R, Gomez J, et al. Predicting the result of noninvasive ventilation in severe acute axacerbations of patients with chronic airflow limitation. Chest 2000;117:823–833.
Concato J, Shah N, Horwitz RI. Randomized, controlled trials, observational studies and the hierarchy of research designs. N Engl J Med 2000;342:1887–1892.
Confalonieri M, Gorini M, Ambrosino N, Mollica C, Corrado A. Respiratory intensive care units in Italy: a national census and prospective cohort study. Thorax 2001;56: Suppl. 5 pt 2 373–378.
American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;152:S77–S121.
Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease. classification system. Crit Care Med 1985;13:818–829.
Teasdale G, Jennet B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;2:81–84.
Marchioli R, Avanzini F, Barzi F, et al. Assessment of absolute risk of death after myocardial infarction by use of multiple-risk-factor assessment equation: GISSI-Prevention mortality risk chart. Eur Heart J 2001;22:2085–2103.
Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyörälä K, together with members of the Task Force. Prevention of coronary heart disease in clinical practice. Recommendations of the Second Joint Task Force of European and other Societies on coronary prevention. Eur Heart J 1998;19:1434–1503.
Pyörälä K, De Backer G, Graham I, Poole Wilson P, Wood D, on behalf of the Task Force. Prevention of coronary heart disease in clinical practice. Recommendations of the Task Force of the European Society of Cardiology, European Atherosclerosis Society and European Society of Hypertension. Eur Heart J 1994;15:1300–1331.
Anderson KM, Wilson PWF, Odell PM, Kannel WB. An updated coronary risk profile: a statement for health professionals. Circulation 1991;83:356–362.
Conroy RM, Pyörälä K, Fitzgerald AP, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003;24:987–1003.
Justice AC, Covinsky KE, Berlin JA. Assessing the generalizability of prognostic information. Ann Intern Med 1999;130: 515:24
Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982;143:29–36.
National Heart, Lung and Blood Institute/World Health Organization Report. Global Initiative for Chronic Obstructive Lung Disease, 2001. NIH Publication No. 2701: 91–92
Confalonieri M, Potena A, Carbone G, Della Porta R, Tolley E, Meduri GU. Acute respiratory failure in patients with severe community-acquired pneumonia: a prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 1999;160:1585–1591.
Confalonieri M, Aiolfi S, Gandola L, Scartabellati A, Della Porta R, Parigi P. Severe exacerbations of chronic obstructive pulmonary disease treated with BiPAP® by nasal mask. Respiration 1994;61:310–316.
Meduri GU, Turner RE, Abou-Shala N, Wunderink R, Tolley E. Noninvasive positive pressure ventilation via face mask. First-line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. Chest 1996;109:179–193.
Meduri GU, Abou-Shala N, Fox RC, Jones CB, Leeper KV, Wunderink RG. Noninvasive face mask mechanical ventilation in patients with acute hypercapneic respiratory failure. Chest 1991;100:445–454.
Vol 25 Issue 2 Table of Contents
Thank you for your interest in spreading the word on European Respiratory Society .
You are going to email the following A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation
Message Subject (Your Name) has sent you a message from European Respiratory Society
Message Body (Your Name) thought you would like to see the European Respiratory Society web site.
European Respiratory Journal Feb 2005, 25 (2) 348-355; DOI: 10.1183/09031936.05.00085304
Impact of home mechanical ventilation on health-related quality of life
Mechanical ventilation affects alveolar fibrinolysis in LPS-induced lung injury
Static pressure–volume curves and body posture in severe chronic bronchitis
Show more Original Articles: Mechanical ventilation
About the ERJ
The European Respiratory Society
Society home
ERS books online
ERS Bookshop
ERS author centre
Accessing the ERS publications
European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
Email: journals@ersnet.org
Copyright © 2019 by the European Respiratory Society


Will a minesweepers attached to a fleet offer any protection against mines?
Straight Arrow wrote: Will a minesweepers attached to a fleet offer any protection against mines?
Yes, but minesweepers are coastal vessels, so you may end up going through more enemy minefields and suffering more damage having them along than you would if you swooped in from the open sea. To add insult to injury, minesweepers have a speed coefficient of 65% and since you usually have to go through more coastal zones than you would if you had used the open sea you will reach your destination MUCH slower.


On 18/11/2017, SUK announced Job notification to hire candidates who completed Any Post Graduate, M.Phil/Ph.D for the position of Director.
2. Qualification: (as per Higher and Technical Education department G. R. No. MIS- 2017/Cr.No.124/2017/Vishi-1 dated 20.04.2017)Ph.D. in Physical Education.Experience of at least 10 years as University Deputy Director of Sports / Physical Education or 15 years as University Assistant Director of Sports / Physical Education / College Director of Sports/Physical Education or 10 years as Certified National Coach,Participation in at least two national/international seminars / conference,Consistently good appraisal report,Evidence of organizing competitions and conducting camps of at least two week's duration,Evidence of having produced good performance team / athletes for competitions at state/national/inter-University / combined University etc.,Preference shall be given to a candidate who has been honored with official State / National level award like Arjun award, Dronacharya award, Shiv Chatrapati award etc.
1. The appointment of the Director of Sports and Physical Education shall be for a term of five years or the age of superannuation, whichever is earlier, and he shall be eligible for re-appointment by selection on the recommendation of a selection committee constituted for the purpose, for only one more term of five years in the university in which he is serving.
2. The candidate must submit declaration in prescribed Form – A, along with the application form as per rule 4 of having small family as per the directives issued by Government of Maharashtra. Form – A is available with the application form.University reserves the right to fill or not to fill the post being advertised.


text:
'use strict';

import { Socket, Server as NetServer, createConnection, createServer } from 'net';
import { TPromise } from 'vs/base/common/winjs.base';
import { IDisposable } from 'vs/base/common/lifecycle';
import Event, { Emitter } from 'vs/base/common/event';
import { Server as IPCServer, Client as IPCClient, IMessagePassingProtocol, IServer, IClient, IChannel } from 'vs/base/parts/ipc/common/ipc';

function bufferIndexOf(buffer: Buffer, value: number, start = 0) {
	while (start < buffer.length && buffer[start] !== value) {
		start++;
	}

	return start;
}

class Protocol implements IMessagePassingProtocol {

	private static Boundary = new Buffer([0]);
	private buffer: Buffer;

	constructor(private socket: Socket) {
		this.buffer = null;
	}

	public send(message: any): void {
		try {
			this.socket.write(JSON.stringify(message));
			this.socket.write(Protocol.Boundary);
		} catch (e) {
			// noop
		}
	}

	public onMessage(callback: (message: any) => void): void {
		this.socket.on('data', (data: Buffer) => {
			let lastIndex = 0;
			let index = 0;

			while ((index = bufferIndexOf(data, 0, lastIndex)) < data.length) {
				const dataToParse = data.slice(lastIndex, index);

				if (this.buffer) {
					callback(JSON.parse(Buffer.concat([this.buffer, dataToParse]).toString('utf8')));
					this.buffer = null;
				} else {
					callback(JSON.parse(dataToParse.toString('utf8')));
				}

				lastIndex = index + 1;
			}

			if (index - lastIndex > 0) {
				const dataToBuffer = data.slice(lastIndex, index);

				if (this.buffer) {
					this.buffer = Buffer.concat([this.buffer, dataToBuffer]);
				} else {
					this.buffer = dataToBuffer;
				}
			}
		});
	}
}

export class Server implements IServer, IDisposable {

	private channels: { [name: string]: IChannel };

	constructor(private server: NetServer) {
		this.channels = Object.create(null);

		this.server.on('connection', (socket: Socket) => {
			const ipcServer = new IPCServer(new Protocol(socket));

			Object.keys(this.channels)
				.forEach(name => ipcServer.registerChannel(name, this.channels[name]));

			socket.once('close', () => ipcServer.dispose());
		});
	}

	registerChannel(channelName: string, channel: IChannel): void {
		this.channels[channelName] = channel;
	}

	dispose(): void {
		this.channels = null;
		this.server.close();
		this.server = null;
	}
}

export class Client implements IClient, IDisposable {

	private ipcClient: IPCClient;
	private _onClose = new Emitter<void>();
	get onClose(): Event<void> { return this._onClose.event; }

	constructor(private socket: Socket) {
		this.ipcClient = new IPCClient(new Protocol(socket));
		socket.once('close', () => this._onClose.fire());
	}

	getChannel<T extends IChannel>(channelName: string): T {
		return this.ipcClient.getChannel(channelName) as T;
	}

	dispose(): void {
		this.socket.end();
		this.socket = null;
		this.ipcClient = null;
	}
}

export function serve(port: number): TPromise<Server>;
export function serve(namedPipe: string): TPromise<Server>;
export function serve(hook: any): TPromise<Server> {
	return new TPromise<Server>((c, e) => {
		const server = createServer();

		server.on('error', e);
		server.listen(hook, () => {
			server.removeListener('error', e);
			c(new Server(server));
		});
	});
}

export function connect(port: number): TPromise<Client>;
export function connect(namedPipe: string): TPromise<Client>;
export function connect(hook: any): TPromise<Client> {
	return new TPromise<Client>((c, e) => {
		const socket = createConnection(hook, () => {
			socket.removeListener('error', e);
			c(new Client(socket));
		});

		socket.once('error', e);
	});
}

redpajama_set_name: RedPajamaGithub


text:
Q: Two textbox dates should not be greater to current date in javascript I have written a javascript condition for checking the date condition.
What my requirement is, I have two textbox in which I add the dates, And what I want to check is that.
My both the dates which are entered into the textbox should not be greater than Current date.
I have tried the below code but it is accepting the date which is greater than system date.
var todayDate = new Date();
   var todayMonth = todayDate.getMonth() + 1;
   var todayDay = todayDate.getDate();
   var todayYear = todayDate.getFullYear();

 var todayDateText = todayMonth + "/" + todayDay + "/" + todayYear;
    var Dt1 = document.getElementById('txtFormDt').value;
    var Dt2 = document.getElementById('txtToDt').value;
  if (todayDateText > Dt1)
    {
        alert("System Date Should be grater than From Date");
    }
     if (todayDateText > Dt2) {
         alert("System Date Should be grater than To Date");
    }

       if (Dt2 < Dt1) {
           alert("To Date Should be grater than From Date");
           return false;
       }
       return true;
  }

A: You can compare Date objects directly using the <, >, >= and <= operators but not == or === since Dates are also Objects. However, make sure you correctly parse the values from the inputs, e.g.

function checkDate(el) {
  var form = el.form;
  var now = new Date();
  var date = parseMDY(form.startDate.value);
  form.parsedDate.value = date;

  if (!date || isNaN(+date)) {
    form.result.value = "Invalid date";
  } else {
    form.result.value = date < now;
  }
}

// Parse string in m/d/y format
// Returns invalid date if month or day out of range
function parseMDY(s) {
  var b = s.split(/\D/);
  var d = new Date(b[2], --b[0], b[1]);
  return d && d.getMonth() == b[0]? d : new Date(NaN);
}
<form id="f0">
  Insert date (m/d/y)<input type="text" name="startDate">
  <input type="button" onclick="console.log(checkDate(this));" value="Check date">

  Input date: <input name="parsedDate" readonly size="50">

  Before today?<input name="result">
</form>

redpajama_set_name: RedPajamaStackExchange


Zila Parishad Tangail authority will send you Admit Card by Post. Also you can visit update news at notice board F-10, Agargong, Civik Sector, Sher-e Bangla Nagar, Dhaka-1207.
Zila Parishad Tangail authority will send you Admit Card, Exam Center and Location. Also you can visit update news at notice Board F-10, Agargong, Civik Sector, Sher-e Bangla Nagar, Dhaka-1207.
Gangachara Upazila Dairy Cooperative Programauthority will published Their notice board. Also you can visit update news at notice board F-10, Agargong, Civik Sector, Sher-e Bangla Nagar, Dhaka-1207.
Tags: Gangachara Upazila Dairy Cooperative Program Facilitator Job Circular 2018, Gangachara Upazila Dairy Cooperative Program Facilitator Application process, Gangachara Upazila Dairy Cooperative Program Facilitator Job Circular 2018, Gangachara Upazila Dairy Cooperative Program Facilitator Job Exam Result, Gangachara Upazila Dairy Cooperative Program Facilitator Job Appliaction Form.
Gangachara Upazila Dairy Cooperative Program Facilitator Job Circular 2018, Gangachara Upazila Dairy Cooperative Program Facilitator Application process, Gangachara Upazila Dairy Cooperative Program Facilitator Job Circular 2018, Gangachara Upazila Dairy Cooperative Program Facilitator Job Exam Result, Gangachara Upazila Dairy Cooperative Program Facilitator Job Appliaction Form.


One of the most hectic tasks one can always experience is selling of a house. Most people always think that selling a home is always through the realtor. However much this method is always effective, not every situation will always need it. The quick house sale is one of the things you will always want to do. You always need to consider getting another alternative for the sale of the house. Selling your house to a real estate investor will always be the best option. There are tones of advantages you will always be guaranteed of when you sell your house to Huge Cash Offer in Phoenix AZ. Some of the benefits will always exist in this article.
When you sell your home to a real estate investor, you will never be required to repair the house. The real estate investor will always take the house as it is. All that the investor will do in case of damages is to adjust the valuation of the home. House repair is, however, one of the must-dos when you always list your house.
With a real estate investor, you will always cut on some cost. With a realtor, you will always be expected to repair the houses which will itself be expensive. You are the one who will always be required to purchase for the materials to repair the house. To add onto that, you will still need to pay the house repair contractors you will have hired. You will still be expected to pay for all of the utility bills and mortgages the house will have when the house will still be in the market.
With a real estate investor, payment of any commissions during the house sale will be out of the question. No services offered by the real estate agent will ever be for free. The bridge that will always exist between you and the home buyer will always be the real estate agent. Therefore, the realtor will always want you to pay for the services as they will never be free. The realtor will always expect either to be paid a periodical commission or a flat fee.
With a cash house buying company in Phoenix AZ, you will always be able to close the house sale much faster. The real estate investor will always come to the house on sale and look at its aesthetic value. After a day, you will always get an offer for the house. You will always get paid on the same day the deal is closed which will always be after a few months. There are a lot of delays you will however always experience when it will come to the listing.
See page to learn more about real estate: https://en.wikipedia.org/wiki/Home_Ownership_Investment.


In this post we review two beautiful books from Book Island – The Big Question and Mr Miniscule and the Whale.
Elephant has been thinking. She has a difficult question that she doesn't know the answer to. How do you know when you love someone?
Fortunately, the Annual Meeting is about to begin, so she asks her friends if they know the answer. Mouse, Snow White, Stone, the sea, the clouds, Apple Tree, the Explorer, Polar bear, the Sun, Grandma and the little girl all share their interpretation of love.
Everyone has an opinion, except busy Ant, who has finally had a chance to chair the meeting and get ahead. Elephant begins to understand the answer but does Ant?
This Large, hard cover picture book is whimsically illustrated with visual magic overflowing on every page. Although the pictures will captivate anyone, the amount of text and abstract concepts are more suitable to school age children. This book will get you talking and thinking. What does love mean to you?
This book was originally written in the 1950s in Polish and its rhyming text has now been translated into English. It is no mean feat to translate a long rhyming tale that flows and still captures the essence of the story. Just as it is no mean feat for tiny Mr Miniscule to accomplish the last thing on his wish list – to see a big blue whale.
This amusing book will captivate children as they journey with the coffee bean sized explorer Mr Miniscule, to see if he can finally find a whale. Will he come home disappointed or will he get more than he bargained for? Enjoy the expedition with the simple yet delightful pictures coloured only in blue and yellow that adds to the quirkiness of the whole adventure.


text:
Home Business Tech Industry
Alcatel continues fibre push
One of French network vendor Alcatel's most senior executives is back in town as the vendor continues to push for a deal that would see Telstra construct a new AU$3 billion fibre broadband network. That network is currently the subject of discussions between the nation's competition regulator and Telstra, with Alcatel standing to gain a substantial amount of revenue if the deal is brokered.
Written by Renai LeMay, Contributor on May 7, 2006
One of French network vendor Alcatel's most senior executives is back in town as the vendor continues to push for a deal that would see Telstra construct a new AU$3 billion fibre broadband network.
That network is currently the subject of discussions between the nation's competition regulator and Telstra, with Alcatel standing to gain a substantial amount of revenue if the deal is brokered.
The vendor's global president and chief operating officer Mike Quigley will meet the press this Wednesday to discuss the nation's need for a new broadband network.
Quigley's visit follows a February trip down under where he was reported to have met with regulators and senior politicians to push Telstra's case to keep its rivals from immediately gaining access to the new network as they do its current copper.
It is likely this week's visit will see the Alcatel president conduct similar talks. Quigley's visit comes at a critical time as Telstra and the Australian Competition and Consumer Commission have been reported to be close to finalising a deal under which Telstra would build the network.
In addition, the federal government is reported to be considering how to regulate Telstra as it prepares to sell the remainder of its stake in the telco in a process known as "T3". Any deal on a new fibre network will affect that debate as well as having implications for the nation's budget, due to be released tomorrow.
Quigley will meet the press flanked by executives from publisher Fairfax Digital and digital media agency Mediazoo. Both companies' long-term success is tied to the nation's uptake of broadband technologies.
Consultant KPMG will also be in attendance. The company recently compiled a report in association with Alcatel claiming to identify regulatory levers that could be used to encourage investment in broadband infrastructure.

redpajama_set_name: RedPajamaCommonCrawl


The MS-07B "Gouf" is a followon suit to the Zeon "Zaku" suits, which had been used since the beginning of the Mobile Suit Gundam series. It bears a family resemblance in the rounded shapes, spikes, and the like.
The kit is one of the "High Grade" series of Gundam kits. These have more parts and typically more articulation than the basic Gundam series of kits (which usually sell for around $5 less, but are the same scale, 1/144.) The same basic assembly style translates between the two sets, with snap-together plastic parts and poly caps in the areas that provide movement.
Assembly was very - well, unremarkable. The fit of the parts are very good, and with care taken when removing them from the parts trees, you shouldn't have any gaps. You might want to use glue on one or two areas - the lower arms, and the arm "spikes" come to mind - but it's not really neccessary.
I've gotten into the habit with these of using my hobby knife to 'shave' the ends of the poly pieces. It gets the very ends of the pivots just a hair smaller, and seems to help the fit tremendously.
One thing you may want to do, whether you paint and weather the model or not, is highlight the panel lines. It is easy to do, and does enhance the look of the model. The panel lines themselves are rather heavy on this model, and makes a basic (though sloppy) technique very easy. Working quickly, you paint black into the panel lines, then wipe it off immediately. The surrounding plastic will remain blue, while the black stays in and shows the lines and vents. Alternately, get a black technical pen with a very fine tip, and just "draw" the lines in.
Having said all that, the weak point in this kit (to me) is the right hand, which is where the weapons are. (Admittedly there are cannons built into the fingers of the left hand, but you can't switch those out.) Contrasting it to its predecessor, the Zaku II, you only get two hands, but three (or four, depending on how you count it) weapons - two "heat rod" whips (one curved, one straight out,) a machine gun, and a sword (stored in the shield, which just clips on to the left arm - very securely, I must add!) You're only given two hands, though - one for the whips, which also must get "clipped" into the fitting just behind the hand, and one for the sword and gun. More hands would have been very nice, as prying the hand apart to fit the other heat rod, the sword, or the gun, is a pain and can lead to the hand breaking or at least not fitting as well. On the Zaku II I was comparing it to, you get another complete hand - the Heat Hawk axe fits in the left hand, and you get two hands for the right, one for the bazooka and one for the machine gun, which can be glued together and left permanently. In addition, the heat rods on this kit (at least the curved one) are odd toit through the hand. The best method I've found was to just trap the rod in, fit the ball end into its fairing, then let it straighten itself out as you clip the hand back on.
All in all, it's another nice kit from Bandai of unusual subject matter. I've said it before, and it's still true - it's a great way to take a break from the "usual" aircraft, ships, cars, or tanks that you may build already. It can also be a great way to spend time with your kids - instead of buying one of the Gundam toys, buy the kit and put it together with them, then let them play with the result. It gives you more 'quality time' (and a bigger end product) than just buying the figures.
Recommended, with a bit taken off for the hand annoyance, to pretty much anyone.


Yesterday was a struggle ~ the second day of Mars in opposition to Pluto… a majorly dynamic joining.
First day was spent at 'home' amongst the trees; and the distant freeway rush. Everyone (well, lots) is in a hurry… we're addicted to speed. God knows why, when we know what awaits us at the end of the road.
I luv the stillness ~ that kind that has many doors; one opening after the next… welcoming you into Sacred Space. It's impossible to describe, you just need to feel it. So many secrets ~ so much wisdom, in those sacred chambers of beingness.
Freeways get larger and longer ~ more concrete poured. Cars blow poisons into our environment. Body's tangled in chords of impatience. Jobs to be done, places to go ~ deadlines to meet; as I sit amongst the trees, discovering new doorways.
There's a lost part of marilyn knocking loudly… wanting presence and a seat at the table. Her presence is palpable… been so long living without her.
Empathic and a 'Healer' type my fields are open… ever ready to help, cheer or heal; it's often unconscious. My chatty, light and warmth long to connect ~ but it's the other part… the strong and straight, decisive, firm and self protecting one; been washed away, flooded by grief. Trauma twists and turns ~ but the foundation's always there.
Why it take the time it does we may never know. Cards, star charts and psychics peek into the mists searching for clues. Right here, right now the miracle breathes.
'Today there'll be evidence of how much I'm loved all around me' I said out loud; it was my vibrational alignment focus for this morning… and gee did it stir some deep emotions, and a well of tears.
Sitting ~ legs outstretched on my comfy bed; back supported by soft white cushions. Chai in hand; beside me Sun's just risen over the ocean… a spectacular view through the long glass doors.
My body's exhausted ~ yesterday was simply too much for my sensitive nervous system. A resting day today.
A new day dawns ~ a fresh opportunity. Dazzled and blessed by Venus on awakening; sitting just above the Pleiades.
The energy is strong ('when isn't it' you might exclaim) during this mid-year crossing. Currently warrior Mars ~ imbued with passion and desire to act, is moving closer to his exact confrontation with Pluto. I've always felt the build up is the strongest energy… that two degree approach.
As always we have choice; these choices clarify where we stand. Mars confronting Pluto can be majorly plutonic… sparks and explosions igniting simultaneously.
Or it can grant you the boon of rebirth… a deep and lasting transformation. We have choice… even if at times it may not appear that way. We cannot escape the law… what we vibrate, we attract to us… like metal filings to a magnet.
My gut/digestion is speaking loudly… been rumbling there for last few weeks; then last week ~ unleashed its full displeasure. Some focused attention needed. I've become familiar with my body during my time on Earth. As Virgo Sun… body is intricately connected to everything. My fields are super sensitive, requiring a gentle approach. I turn to what I know, I listen and strive to understand. 'What's the disharmony… what's ill at ease?' Well ~ seven moves in five months, since leaving my sacred space is a start. Then the twists and turns, ancient memories and emotions still stored in my body. We need to heal to be our self.
Healing has been a major focus of mine for a long time. Introduced to the world of sickness, death and disease; and the modern medical system, at the tender age of three. I've observed a lot… taken in many impressions.
I've trusted my sight and sort my own way.
This year will be 66 years since my little life changed; a magick number ~ a Master Number. Speaks to me of love, family, nurturing and creativity. That new chapter I saw and heard approaching; two years prior to leaving Mahalia. I saw the beauty, the sacred space that awaited me. I also felt the fear and shock, the terror of leaving this place I was so deeply connected to. My sacred home of such incredible beauty… a place that took me in and held me close; nurtured me in an unimaginable way. There's so much we don't see with our eyes.
I trusted the message ~ I heeded the call… I needed to be prepared to leave Mahalia. Was I that brave… was I that courageous?
The move was tough… almost claimed me. It took my body to the edge… it's a journey I've not taken before. But I trusted the message ~ my most important chapter was approaching. I needed to let go… and follow the voice.
So the 7th move ~ back amongst the trees; my body needs rest and nurturing… especially amid these deeply stirring energies. Something wants to be released ~once and for all. Let go, let go… what does it teach us, this letting go thing?
The sky is light, soon Sun will rise… another day to celebrate.


man. what do you want?
woman. what do i want?
m. yes, what do you want?
w. i don't want anything.
m. why don't you want anything?
w. because i don't think anything is gonna help.
m. what do you mean by that?
m. do you live around here?
m. i don't have anywhere to go.
w. what do you want?
m. i don't want anything from you – that's for sure.
m. what do you want?
w. what do i want?


text:
FedEx Recruitment for 2008 in France
FedEx announced 200 recruitments for 2008 in France, corresponding to the dynamism of the express sector, and specially, to the growth of FedEx activities in France, with the European hub in Roissy-CDG and all French agencies.
Aurélie Morin, Human Resources Director of FedEx Express France, explains FedEx recruitment approach: local employment privileged, partnerships with regional organizations for recruitment, diversity, etc. Key elements and values of FedEx HR strategy are described too. These elements ranks FedEx among the 20 first "Great places to Work".
FedEx has developed a strong corporate social responsibility. For example, its commitment with the Foundation of France and the association Papa Charlie are described. FedEx signed the Charter of Diversity to show all its efforts in this field.


Collection Defense RI | Henry V. Boezi III, P.C. | Henry V. Boezi III, P.C.
According to current surveys, seventy-eight (78 %) percent of full-time workers state that they live paycheck to paycheck. Other surveys have concluded that persons over fifty (50) years of age have an unprecedented amount of debt.
These circumstances can lead to greater financial difficulties and result in activity initiated by creditors to collect a debt, mostly credit card debt. If these efforts are unsuccessful, a lawsuit is frequently filed to collect the money claimed to be owed by the debtor.
A person seeking to file bankruptcy is likely to have been sued in at least one collection matter.
The Law Office of Henry V. Boezi III, P.C. almost always negotiates very favorable monthly payments for those of our clients who do not dispute the validity of a debt, and has done so in numerous cases.
If our client disputes the debt, however, we will assert and use any applicable defense he or she may possess in defending the collection matter for them.


Buspar bar pill tadalis 20mg reviews tadalista 40 mg diflucan over the counter in uk buy lexapro in canada is diflucan over the counter. Deutsche online apotheke viagra helpful online pharmacy acheter viagra france tadalis dose lexapro price ireland cost of lexapro no insurance. Viagra online schweiz can you buy propecia over the counter in canada tadalis 10 mg cost of lexapro 5mg. Average cost of lexapro 20 mg tadalis 20mg tadalista 20mg tablets viagra online apotheke empfehlung buspar and sleeping pills viagra online apotheke schweiz. Eu online apotheke viagra price of lexapro in ireland tadalista 20 dosage diflucan and over the counter creams lexapro 10 mg price ireland. Is diflucan over the counter drug cost of lexapro 20 mg without insurance comprar viagra online italia tadalis 20mg opinie. Erfahrungen online apotheke viagra how much does lexapro 20 mg cost diflucan available over the counter buy tadalista 20mg. Cost of lexapro 10 mg without insurance viagra pfizer online italia tadalista 20mg super active where can i buy propecia in canada online apotheke schweiz viagra. Viagra online aus deutschland propecia buy canada buy lexapro canada pharmacy online apotheke für viagra. Tadalista 20 mg reviews online-apotheke viagra-bestellen buying lexapro online canada buy generic propecia online canada lexapro online ireland. Online apotheke viagra deutschland order lexapro online canada buspar pill effects generic lexapro cost cost of lexapro vs celexa. Best drugstore shampoo hair loss can you buy lexapro from canada propecia where to buy canada generic for lexapro cost tadalista 20 mg seriöse online apotheke viagra. Diflucan over the counter in australia lexapro cost northern ireland tadalis oral jelly can you buy propecia in canada. Viagra in online apotheke viagra for sale germany tadalis sx 20 mg ajanta pharma tadalis sx dosage generic viagra online pharmacy usa. Average cost of lexapro 10 mg buy lexapro online canada what does generic lexapro cost buy propecia in canada tadalista 40 mg review. Tadalis sx soft 20 mg sichere online apotheke viagra online apotheke viagra mit rezept online apotheke viagra generikum propecia buy online canada over the counter drugs similar to diflucan. Lexapro 20 mg from canada buy propecia canada pharmacy viagra online in ireland generic lexapro cost without insurance lexapro vs celexa cost. Viagra schweiz online bestellen viagra originale online italia lexapro cost canada viagra online in spain tadalista ct 20 mg cost of lexapro vs generic. Tadalista 20mg reviews buspar pill buspar sleeping pills get diflucan over the counter tadalis sx 40 mg.
Generic viagra canadian pharmacy online buy viagra montreal average cost of lexapro 20 mg cialis online buy levaquin online pharmacy. Buying tretinoin online price for lexapro 20 mg buy benadryl online lexapro price canada can i buy viagra in canada over the counter. Lexapro 10 mg price lexapro buy canada cheapest pharmacy price for viagra where to buy viagra in quebec. Buy lexapro in canada buy cialis online without a prescription buy lexapro canada cost of lexapro 20 mg cialis online best place buy. Viagra 100mg for cheap lexapro vs generic price buy brand cialis online usa cheaper alternatives for viagra cheap viagra for sale in australia. Lexapro online prescription where can i buy cialis online usa buy cialis online usa price for lexapro 10 mg. Where to buy cialis online in usa price of lexapro 10 mg pharmacy online us cheap alternative for viagra alternatives to viagra for ed. Buy benadryl online uk buy viagra in edmonton cost of lexapro no insurance cost of lexapro vs celexa buy viagra canada how much weight does lexapro make you gain. Buy lexapro from canada where can you buy viagra in canada real viagra for sale uk cheap substitute for viagra can you buy viagra in canada. Average cost of lexapro 10 mg online prescription for viagra real viagra for cheap levaquin 500 mg online buy benadryl online india. How much does lexapro 10 mg cost Can u buy clomid uk buy iv benadryl online buy cialis online with prescription where can i buy viagra in edmonton cheap price for viagra. Where buy viagra in canada real viagra for sale online cost of lexapro prescription buy cialis online worldwide shipping ventolin rezeptfrei kaufen. Online viagra for sale buy viagra quebec buy viagra in canada buy benadryl plus online buy levaquin online uk lexapro vs celexa cost cost of non generic lexapro. Cost of lexapro 5mg buy cialis online in us benadryl online discount how much does lexapro generic cost price of lexapro 20 mg retail price lexapro 20 mg. Buy viagra from canada generic price for lexapro average cost of lexapro 20 mg alternative to viagra for heart patients buy lexapro canada pharmacy buy pfizer viagra in canada. Buy lexapro online canada buy cialis online us buy cialis online melbourne cost of lexapro brand ez online pharmacy buy cialis usa. Generic viagra prices in canada buy cialis online without prescription cost of lexapro australia lexapro 10 mg retail price buy cialis online uk cheap. Levaquin buy online best generic for viagra real viagra for sale cialis buy cheap online ventolin kaufen ohne rezept. Buy levaquin online lexapro cost canada how much lexapro for depression buy viagra in canada online.
Buy prozac online uk buy prozac online canada buy propranolol australia buy prozac online nz buy cialis online in europe buy cialis online canada pharmacy. Buy tamoxifen citrate online lexapro 10 mg retail price weight loss after discontinuing lexapro hyzaar 100-12.5 tablet. Lexapro topamax weight loss buy cialis online overnight shipping buy cialis online free shipping hyzaar 100/12 5 mg 28 film kapli tablet. Buy propranolol online australia buy cialis pills online propranolol buy online australia nolvadex next day delivery uk buy cialis online in uk. Buy cialis professional online buy cialis online in spain lexapro and wellbutrin together weight loss buy prozac online ireland. Tapering off lexapro weight loss buy generic prozac online successful weight loss after lexapro buy tamoxifen online cheap buy tamoxifen online. Buy prozac online in uk buy cialis online united states buy tamoxifen tablets online lexapro and adderall weight loss buy cialis online switzerland lexapro 10 mg discount. Lexapro for ocd weight loss buy prozac tablets online buy prozac online europe buy cialis online overnight delivery. Tamoxifen to buy online can i buy prozac online uk buy cialis with dapoxetine online buy real prozac online lexapro and weight loss depression. Buy nolvadex next day delivery buy prozac online safe cost of lexapro brand weight loss pills with lexapro. Buy tamoxifen online australia buy nolvadex fast delivery can you buy prozac online buy prozac online canadian pharmacy buy prozac online cheap tamoxifen citrate buy online. Buy cialis online pharmacy buy cialis online next day delivery buy cialis online fast shipping generic online pharmacy uk. Buy tamoxifen online usa generic lexapro cost without insurance hyzaar 100-25 tablet buy brand prozac online hyzaar forte tablet. Hyzaar 28 film tablet weight loss on lexapro 10 mg where can i buy tamoxifen online buy cialis soft online hyzaar 50-12.5 tablet lexapro and wellbutrin weight loss. Buy cialis online fast delivery can i buy prozac online buy prozac fluoxetine online lexapro and weight loss/gain buy cialis online prescription buy cialis doctor online. Tamoxifen buy online uk hyzaar fort 100/25 mg 28 film tablet fiyatı where to buy tamoxifen online zoloft vs lexapro weight loss. Weight loss when stopping lexapro hyzaar fort 28 film tablet lexapro vs generic price tamoxifen buy online lexapro printable coupons discount code.
Dulcolax tablets dosage instructions dulcolax recommended dosage dulcolax stool softener 100 mg recommended lexapro dosage for ocd dulcolax dosage 10 mg. Dulcolax 5mg tablets lexapro 10 mg cost dulcolax usual dosage dulcolax bisacodyl tablets 5mg dosage dulcolax dosage oral dulcolax suppository dose for adults. Dulcolax dosage liquid lexapro full price dulcolax 5mg directions bisacodyl dulcolax dosage lexapro 20 mg best price. How safe is it to buy viagra online dulcolax suppository dosage for adults dulcolax 50 mg dulcolax 5mg used for dulcolax 10 mg tablets lexapro dosage for generalized anxiety disorder. lexapro 10 mg price dulcolax 5 mg dose dulcolax 20 mg purchase viagra online canada lexapro cost canada lexapro dosage for anxiety 5mg. Dulcolax tablets maximum dosage dulcolax dual action tablets bisacodyl 5 mg 100 safest place to buy viagra online. Kegunaan obat dulcolax bisacodyl 5 mg hoodia lip gloss uk where to buy cheap kamagra Can you buy diflucan over the counter in the united states lexapro generic cost rite aid. Dulcolax dosage adults dulcolax maximum daily dose dulcolax dosage mg dulcolax cat dose buy dutasteride online australia. Dulcolax dosage colonoscopy hoodia liquid uk dulcolax bisacodyl tablets 5mg dosage generic accutane results accutane generic cost without insurance buy dutasteride online. Dulcolax dosage for severe constipation dulcolax 5mg use lexapro price dulcolax bisacodyl 5mg dosage. Dulcolax stool softener liquid gels dosage dulcolax dosage drugs.com lexapro generic cost no insurance dutasteride buy online dulcolax dose adults dulcolax 5mg dosage instructions. Dulcolax tablets 5mg bisacodyl dulcolax 5 mg dosering dulcolax safe dose range dulcolax suppository maximum dosage generic lexapro 20 mg cost dulcolax 5mg how many. Cost of lexapro in australia dulcolax maximum dosage dulcolax dosage india dulcolax dose for adults buy cheap kamagra oral jelly Lexapro 20mg $102.19 - $1.14 Per pill. Hoodia max uk dulcolax pills dosage how much does lexapro generic cost pharmacy online usa viagra dulcolax laxative tablets dosage. Cost of lexapro prescription dulcolax dosage instructions lexapro price rite aid.


Group B at the Copa America looked as though it would most likely have Argentina and Uruguay moving on after the group stage, but after the first round of games, everything appears to be up in the air. Both of the soccer betting favorites were not at their best in the first set of games, and now they will have to face each other on Tuesday night knowing that a loss could leave them in some real trouble.
Date/Time: Tuesday, June 16 at 7:30 p.m. EST Location: Estadio La Portada, La Serena, Chile Opening Line: Argentina -½-150 Argentina are likely to be the more desperate of the two teams, as a loss here would very likely put the second round out of their reach, assuming that Paraguay knock off Jamaica as expected. There really is no reason for them to be in this position, as they looked to be in total cruise control against Paraguay in their opening game. Aguero and Lionel Messi has staked Argentina to a 2-0 lead at the half, but they then seemed to switch off, allowing Paraguay back into the game en route to a 2-2 tie. While Uruguay did not look particularly convincing in their opening match, they were still able to get out with a 1-0 win and 3 points. Argentina could still find a way into the next round with a loss or a tie, but you would have to wonder how inspired Paraguay and Uruguay would be to win if they met in the final round of the group knowing that a tie would take them both through. While Uruguay will be happy, if not totally satisfied, with their 1-0 win over Jamaica, they will also be well aware that they will need to be a whole lot better against Argentina if they want to get anything out of this game. This is a team that looks a shadow of its former self, with many of the key players now well into their 30's. They are not really built for a long tournament run, and without the still banned Luis Suarez leading the attack, they do not have a lot of teeth up front. Edison Cavani is being asked to fill the goal scoring role, but he looked totally frustrated against Jamaica. These two teams met twice during World Cup qualifying, and split the games with a win apiece. There were 8 goals scored in those 2 games, but I don't expect that sort of output this time around.


text:
BlacKkKlansman review – a blistering return to form for Spike Lee!
By ArtHouse, 26 Aug 2018
Mark Kermode makes BlacKkKlansman his film of the week!
Spike Lee's Cannes grand prix winner is the director's best work since his Oscar-nominated 1997 documentary 4 Little Girls. Combining the stylistic slickness of 25th Hour with the controversial potential of Bamboozled, it's a stranger-than-fiction tale ("based upon some fo' real, fo' real shit") of an African American cop infiltrating the Ku Klux Klan in the early 1970s.
Produced by the team behind Get Out (it was Jordan Peele who brought the story to Lee), BlacKkKlansman slips seamlessly from borderline-absurdist humour to all-too-real horror, conjuring an urgent blend of sociopolitical period satire and contemporary wake-up call.
To read the full review, click HERE!
For tickets to see this funny, intelligent and very poignant film click HERE!


text:
Q: How to write unittest for a module which is only supported in Python >(3,0) while the rest are supported across all the version? I want to exclude certain unit tests from running if the test are running in python < (3,0). I tried using @unittest.skipIf to skip the class of tests. Tests are excluded but the import statements are still executed which results into import errors as certain libraries used for the module is not installed if python < (3,0).

A: You could use the following:
import sys
if sys.version_info[0] < 3:
    # unitests

This will check the python version, and only when that python version is what you want it will run.


text:
Galway Advertiser, Thu, Dec 10, 2015
A new report has Toyota as the most reliable brand in Germany with a total of 14 top 10 positions.
The Japanese brand has emerged as the big winner in the 2016 TÜV report. Toyota even featured seven times among the top five in different age categories. And like previous years, the models exhibited particularly few defects in general inspections.
The Toyota Prius is one of the most reliable road companions, taking second place in both the six to seven-year-old and eight to nine-year-old categories. The hybrid pioneer was in good company in both age categories: with the Auris and Yaris taking fifth and sixth place in the six to seven-year old vehicle category.
In the eight to nine-year-old group, the brand's excellent result was rounded off with the Corolla Verso in fourth position, the RAV4 in sixth, the Yaris in seventh and the Corolla in 10th place.
In the 10 to 11-year-old vehicle category, Toyota also demonstrated that age is no barrier to reliability with five models ranking among the top seven. The Corolla Verso and RAV4 earned podium positions in second and third place, closely followed by the Avensis at number four. The sixth and seventh places went to the Corolla and Yaris.
Among the newer vehicles, Toyota recorded another top result with the Yaris, ranking ninth in the two to three-year-old vehicle category.
Volvo launches sporty R-Design of new XC90
Audi Q7 e-tron hybrid SUV on the way
Even better new Kia Optima on the way
New Mercedes-Benz GLE and GLE coupe on the way
Rafterty is a model for up and coming rally drivers
Subaru previews next Impreza at Los Angeles Show
Get set for 161 with Bradley Renault
Skoda Octavia RS is more relevant
Drivers urged to prepare their cars for winter
Join the fun of 161 at Motorpark on Saturday
Test drive the new Audi A4 at Audi Galway's launch
Now that is quality from Toyota
Toyota is No 1 for re-sale value in Ireland
Toyota is number one for re-sale value in Ireland
New Toyota Yaris hybrid on the way
Toyota showcases new model line-up
Toyota, Nissan, and Honda recall thousands of cars
Toyota extends 'cash back' offer on selected models
Toyotas pass NCT tests with flying colours
Toyota 192 New Generation event
Toyota Verso-S wins the space race


text:
AccessReel Reviews – Captain America: The First Avenger
"Captain America: The First Avenger" will focus on the early days of the Marvel Universe when Steve Rogers (Chris Evans) volunteers to participate in an experimental program that turns him into the Super Soldier known as Captain America. As Captain America, Rogers joins forces with Bucky Barnes (Sebastian Stan) and Peggy Carter (Hayley Atwell) to wage war on the evil HYDRA organization, led by the villainous Red Skull (Hugo Weaving.)
It was the year 1940 when Joe Simon and Jack Kirby created Captain America and since then over 210 million Captain America comic books have been sold to add to that there has been numerous television animated series and even a Live Action film back in 1990 which hardly got seen but now we have the Marvel juggernaut coming off the THOR gravy train and smashing our screens with CAPTAIN AMERICA: THE FIRST AVENGER.
Captain America was never something I knew too much about, I have friends who are crazy comic book fans and we have had the odd discussion here and there and when the film was green lit and the cast started building I'm like okay good choice, but then Chris Evans gets cast as Steve Rogers I was somewhat skeptical as I always thought Captain America was tall and built like a tank but obviously I didn't know the backstory I only knew him as the Poster Boy for the American Military, but as usual after watching the film I went and read everything I could as Captain America is up there with my favorite 3 films this year so far.
There's three factors which make this film great, Chris Evans by far embodied the role of Steve Rogers from start to finish even from when he's playing the sickly young man who continues to fail at getting into the Military to when he don's the Captain America suit and hammers HYDRA's infantry there's even quite the comedic element to a bunch of scenes as well and as we all saw in 'Fantastic Four' Evans can pull it off rather easily. Hugo Weaving who plays the villain in the film 'Red Skull' did an amazing job sometimes I think it's hard to pull off a true villain but Weaving done it with complete ease and creepiness! Finally, The CGI and special effects in this film are flawless and just so damn impressive, so right their there's 3 things that just win for me, Great Lead, Sensational Villain and incredible CGI.
The story as well sparked something with me, here's this young sickly man who has so much drive and passion to succeed and join his fellow countrymen in the fight he just continues to try and try again and even when he gets knocked down he gets back up and continues to push. I think there's a certain scene in the movie when a 'dead' grenade gets thrown at the 'team' in training and they all scatter but Rogers jumps straight on it with no hesitation, that right there really sums it up.
Performance wise everyone brought there A-Game, I've already mentioned Evans and Weaving, but also Tommy Lee Jones as the hardass Col. Chester Phillips, some of the one-liners he has are hilarious. Hayley Atwell as Peggy Carter, just so incredibly gorgeous and nails it as Rogers love interest. Dominic Cooper as Howard Stark, it was great to see Stark in this film the whole Avengers Story arc is working a treat and I'm loving every reference and finally Stanley Tucci as Dr. Abraham Erskine, what can I say, Tucci can do anything!
With "The Avengers" coming up quickly well somewhat I am really excited about what the future holds for this entire franchise, Marvel just seems to do everything right. From the Iron Man films to Thor and now Captain America each film is just solid in every way and for you fans out there I think waiting for the credits to finish is a must, the only thing about Captain America I would have liked to have seen a bit more of was the military training, we saw bits of this before he became Captain America but it just felt to me that he became a super soldier and on with the fight (except for dancing with girls for bonds), but that is such a small issue for such an awesome film.
CAPTAIN AMERICA: THE FIRST AVENGER is in cinemas tomorrow I give this film a 4.5/5
You can check out the trailer to CAPTAIN AMERICA: THE FIRST AVENGER right here.


text:
Home Art News Extending the Runway: Tatiana Sorokko Style Makes U.S. Debut
Extending the Runway: Tatiana Sorokko Style Makes U.S. Debut
PHOENIX, AZ.- After a highly-anticipated and celebrated unveiling at the recently opened Russian Fashion Museum, Moscow, Extending the Runway: Tatiana Sorokko Style makes its U.S. debut on September 16, 2010, at Phoenix Art Museum. Curated by Phoenix Art Museum Fashion Design curator Dennita Sewell, the exhibition features a collection of more than 60 garments and accessories from Sorokko's extraordinary couture wardrobe. Extending the Runway: Tatiana Sorokko Style will be on view through January 2, 2011. Tatiana Sorokko was the first Russian model to achieve international success. Moving from Moscow to Paris in 1990, she walked the runways for major designers such as Yves Saint Laurent, Hubert de Givenchy, Karl Lagerfeld, Miuccia Prada, Issey Miyake, Alexander McQueen, Marc Jacobs, and Calvin Klein, among many others. For over a decade, Sorokko graced the covers and editorial pages of European and American magazines such
tatiana-sorokko
tatiana-sorokko-phoenix-art-museum
Previous articleSaint Louis Art Museum Receives Major Gift from Danforth Family
Next articleNew Works, Inspired on Childhood Games, by Adam Fuss at Cheim & Read
Steven Holl Architects Chosen to Design the New Queens Library at...
Sotheby's New York to offer four monumental bronze sculptures by Henri...


text:
TOP SERVICES & SPECIALTIES
Cancer Care at WPH
Maternity Program
Orthopedics/Spine
Contact WPH
Visit WPHPA.org
Financial Insurance Information
Visiting Hours & Information
Everyday Healthy Cafe
Map, Directions & Parking
Area Accommodations
Connect to Health Information & Patient Portal
Share my Patient Story
View Hospital Charges
Our Facilities & Locations
Friends of White Plains Hospital
Affiliations, Accreditations & Awards
NEWS & MEDIA...
healthTALK Podcast
Our Marketing Campaign
Donate to WPH
Pick a Daisy (Nurse Recognition)
Receive Health Matters Magazine
Volunteer at WPH
Stay Connected with WPH
Our Cancer Program Survivorship
Historically, the term "cancer survivor" has had a variety of meanings. However, the more recently adopted definition refers to any person who has been diagnosed with cancer. As such, survivorship begins with the time of diagnosis and is inclusive of all subsequent time periods in that individual's life – including the periods of initial treatment, cancer-free survivorship, chronic or intermittent cancer activity, and palliative care.
COMPONENTS OF SURVIVORSHIP CARE
Cancer patients, their caregivers and physicians must deal with a unique set of medical and psychosocial issues, which include the following critical components:
Surveillance for spread or recurrence of the initial cancer or second cancers
After treatment of a primary cancer, survivors are at increased risk of recurrence, which may occur at the primary site (local regional recurrence) or in a distant site (metastatic spread). Additionally, they are at increased risk of developing a secondary malignancy (i.e. a different type of cancer and also called "a new primary malignancy") , either as a consequence of chemotherapy or radiation treatment or due to genetic, environmental, or lifestyle factors (e.g. smoking, obesity, etc.).
Attending to the psychosocial well-being of the cancer survivor
As a consequence of the disease and/or treatment, cancer survivors have an increased frequency of a number of psychosocial difficulties including anxiety, depression, fatigue, cognitive limitations, sleep disturbance, sexual dysfunction, and pain. These difficulties can be addressed and managed by patients and their physicians to try to minimize the adverse impact on quality of life.
Monitoring for long-term and late physical effects of cancer and its treatment
Cancer patients are at increased risk of long-term and late effects related to both their disease and its treatment, and these effects are of increasing importance as cancer survival rates improve. One such common effect in female cancer patients is premature menopause. Additional commonly reported effects include peripheral neuropathy and heart dysfunction. For some long-term or late effects, early identification and intervention may improve long-term function and reduce disability and possibly even reduce mortality. Thus, it is important that survivors are seeing health care providers who have an awareness of the potential for late effects of the treatments they received.
Attending to the fiscal well-being of the cancer survivor
Cancer survivors may face financial issues that cause psychological distress and interfere with receiving adequate medical care. If issues are identified, patients can be referred to hospital or community social workers, case managers, and patient assistance programs. They can be assisted by the social worker to complete the necessary paperwork to qualify for additional assistance to decrease the financial burden.
Coordination of care between specialists and primary care providers
Many cancer patients have additional medical conditions (co-morbidities) that were present prior to their cancer diagnosis or treatment or developed after treatment, and these conditions also need to be monitored and appropriately managed. The follow-up of cancer survivors can be shared by many physicians, including cancer specialists, primary care physicians, and other specialists. Coordination and collaboration between the cancer specialist, primary care provider, and other specialists involved in the patient's care can ensure that all of the survivor's health needs are met.
It is important that preventive measures and screening evaluations that may benefit a cancer survivor are appropriately included in their care and follow-up (e.g. flu vaccine, colorectal cancer screening in an individual who has undergone resection of an early-stage lung cancer). Additionally, lifestyle modifications, including healthy diet, physical activity, smoking cessation, and limitation of alcohol consumption, are important in improving quality of life, decreasing the risk of other diseases such as diabetes and heart disease, and potentially decreasing the risk of cancer recurrence.
Cancer Care/Oncology
About Cancer Care at WPH
Our Partnership with Montefiore
Cancers & Conditions Treated
Lung & Thoracic Cancer
Orthopedic Oncology
Skin Cancer & Melanoma
Integrative Services
Am I eligible for a clinical trial?
Patient Resources & Services
Patient Brochure
Colorectal Screening
Head & Neck Screening
Pancreatic Screening
Our Physicians and Staff
Cancer Outcomes Report 2019
Cancer Annual Report
Cancer Survivor Resources
Narrative Writing
Caregiver Support Program
Hair and Makeup lessons
Gilda's Club
American Cancer Society (ACS)
Click here for more information regarding the Center for Cancer Care programs and workshops
Hospital Main Number 914-681-0600
Center for Cancer Care 914-849-7500
Return to WPH Website
View Hospital Standard Charges
WPH Physician Associates
Medical Board Portal
WPH Foundation
Medical & Dental Staff Portal
Nurses Portal
© 2020 White Plains Hospital. All rights reserved.
A Member of the


It wasn't until 2017 that TIME Magazine honored women silence breakers as their "Person of the Year." Truth be told, women have been breaking the silence on abuse and harassment for centuries. They have often been God's hands of compassion and liberation, working to expose evil and topple systems of oppression. Reflecting on women's history of silence breaking is a spiritual discipline that nurtures our souls and forges bold leadership across time and culture. And who better to contemplate than Esther, whose silence breaking opposed the powerful and prevented a genocide by standing with God and the vulnerable! Then and now, holy leadership is often the best resolution to wicked and unjust rulers and regimes. With every retelling of her story, a godly force is kindled within us, compelling us to join in Esther's legacy of silence breaking today.
While rulers worldwide too often dominate and exploit others, looking only to their own interests, Esther used her privilege to align with despised outsiders oppressed by the powerful. The story of Esther demonstrates how authentic leadership is forged in intimacy with God and manifest in attention to the defenseless. Completing what Vashti began, Esther risks all for good, breaking the silence to expose her husband's abusive regime as it amasses toward a genocide. As the story unfolds, so do the contrasts between good and evil, between righteous and corrupt leadership. With their thirst for control and exploitation, Haman and Xerxes provide a stark contrast to the bold and holy leadership of Queen Esther.
A lust for power—rooted in narcissism—swallows Haman whole. Yet equally depraved is King Xerxes! He promotes Haman to chief of staff despite his lack of accomplishments or his interest in the affairs of Susa or its people. Some commentators also believe that Haman may have been complicit in a plot to assassinate the King, averted only through the loyalty of Esther and Mordecai. Even so, Xerxes honors Haman, decreeing that all must kneel in homage. Mordecai refuses—a move that ignites Haman's vindictiveness, and so he plots to kill Mordecai and massacre the Jews. Appealing to Xerxes' greed, Haman asks to slaughter the Jews. Without a second thought, Xerxes agrees and both head off to get drunk.
Abdicating his responsibilities to corrupt officials, Xerxes is inaccessible and derelict as a leader. More interested in pleasure than serving the needs of his people, his indecisiveness and self-indulgence create a leadership vacuum, filled initially by Haman but ultimately by Esther—a genuine leader, a woman, and a Jew.
Unlike the inaccessible Xerxes, Queen Esther is always on hand, attentive to the vulnerable, and ready to act. She is available intellectually and maneuvers within an honor/shame culture to secure safety for the Jews. Esther is especially available spiritually. While Xerxes wallows in wine and women, Esther fasts and prays.
Esther embodies what her husband can't—leadership that defends the vulnerable. Her husband signs away their lives, but Esther becomes their deliverer. Esther gives her people a voice, breaking the silence on Haman's plot and delivering them from slaughter. Unlike Haman, who is bent on destroying life, Esther is ready to give her life to save others. While Haman believes he controls his destiny and that of his enemies, Esther is humble and contrite. For her, the future is unclear, but she is ready to die if necessary.
Esther's availability, self-sacrifice, humility, and holy wisdom make her one of the great leaders in Scripture. What we see in Esther is found supremely in our savior Christ—who delivered us from our worst enemies, sin and death. Because of Christ we enter a complete rest, just as the Jews entered shalom and rest from their enemies because of Esther. In this way, Esther foreshadows our complete deliverance in Christ.
A woman leader, representing a hated minority, Esther responded to God's call, risking her life to break the silence and stand against evil and abuse of power. In a patriarchal culture like Susa, God chose a woman as a deliverer. Scripture honors Esther (9:29) as a woman in full authority.
This Women's History Month, let's honor Esther by imitating her example of leadership—characterized by prayer, courage, and self-sacrifice on behalf of the marginalized. The name "Esther" means "star." May we—like Esther—shine God's light on injustice, expose oppression, and break the silence on abuse wherever we find it.


So you have all these great drink recipes made by your bar staff in different locations around the city, state or country. They make it onto a menu for one season in one location – and then you need another menu for next season and so on. Or, you want to pull a drink special list with drinks for Valentine's day and just your luck, you can't find last year's list.
The solution is an affordable database application that let's you create, store, share and place those recipes into saved menus. That way, any location can go in and quickly pull recipes tagged for Valentine's Day, St. Patrick's Day or Halloween – all with just a few key strokes.
Imagine the time saving. Imagine the asset you would be creating over time. Imagine the happy customers who crave variety and will reorder more.
Like to see more or understand the workings of this type of customized system in more detail? Simply contact us for more information.


text:
Placówka Straży Granicznej w Barcianach – graniczna jednostka organizacyjna Straży Granicznej realizująca zadania w ochronie granicy państwowej.

24 sierpnia 2005 roku funkcjonującą dotychczas strażnicę SG w Barcianach przemianowano na placówkę Straży Granicznej w Barcianach.

Terytorialny zasięg działania
Z dniem 21.12.2007 roku powiększono terytorialny zasięg działania poza strefę nadgraniczną o powiat mrągowski i gminę miejsko-wiejską Kętrzyn z powiatu kętrzyńskiego.

W 2011 placówka Straży Granicznej w Barcianach ochraniała odcinek od znaku granicznego nr 2225 do wschodniego brzegu rzeki Oświnka (na wschód od znaku granicznego nr 2176).

Linia rozgraniczenia:
 z placówką Straży Granicznej w Węgorzewie: wschodnim brzegiem rzeki Oswinka do granicy gmin Srokowo oraz Węgorzewo, dalej granica gminy Srokowo oraz Węgorzewo.
 z placówką Straży Granicznej w Sępopolu: włącznie znak graniczny nr 2225, dalej granica gmin Sępopol i Korsze oraz Barciany.

Poza strefą nadgraniczną obejmuje powiat mrągowski, z powiatu kętrzyńskiego gmina Kętrzyn (g.m-w).

Przejścia graniczne
Od 1.09.2007 roku placówka obsługuje
 kolejowe przejście graniczne Skandawa-Żeleznodorożnyj
wcześniej podległe pod PSG w Bezledach. Przejście obsługuje całodobowo ruch pociągów towarowych, a kontrola graniczna odbywa się w punkcie odpraw w Skandawie i w Kotkach-Wielewie.

Komendanci placówki

 ppłk SG Wiesław Dyśko (16.08.2002-?) ← wcześniej jako komendant strażnicy

Przypisy

Bibliografia

Barciany
Barciany

redpajama_set_name: RedPajamaWikipedia


Dr. Amy Hubbard joined Pediatric Associates in 1999. She attended medical school at the Medical College of Georgia and completed her pediatric training at the University of Tennessee Health Science Center and Le Bonheur Children's Hospital. She is a fellow of the American Academy of Pediatrics.


text:
Archives by date > 2007 > April > 13th
Up to $149M to Preserve US Submarine Fleet
Apr 13, 2007 05:33 UTC
688I-Class SSN: Drydocking
BAE Systems Ship Repair recently received an indefinite delivery/ indefinite quantity contract by the Mid-Atlantic Regional Maintenance Center (MARMC) for blast, paint and preservation work on tanks of nuclear submarines home ported in Norfolk, Virginia. This 5-year contract includes a base year plus 4 one-year options, and presents the opportunity to bid on portions of a work package estimated at $149 million. While BAE has mobile teams on the East and West Coasts and in Hawaii, all work on this contract will take place in Norfolk, VA.
In addition to its non-nuclear ship repair capabilities, BAE Systems provides key hull preservation services to the nuclear submarine force and specializes in corrosion control and habitability work for U.S. Navy ships. BAE Systems release.
USA: $12.4M Order for Semis Hitting the Road
M915s in theater
(click to view larger)
The M915 family are almost carbon copies of commercial tractor-trailer trucks; many of them are being up-armored with Crew Protection Kits for service in combat zones.
Well-known truck manufacturer Freightliner LLC in Portland, OR recently received a delivery order amount of $12.4 million as part of a $551.3 million firm-fixed-price contract for M915A3 Semis, M916A3 Light Equipment Transporters, and M915 Flatbed Trucks. Work will be performed in Portland, OR and is expected to be complete by Feb. 28, 2008. Bids were solicited via the World Wide Web on April 21, 2000, and 2 bids were received by the U.S. Army Tank-Automotive and Armaments Command in Warren, MI (DAAE07-00-D-S022).
This would appear to be the final delivery order; other Freightliner delivery orders were announced under this contract, whose number and negotiated date remain the same as the final amount changes: Sept 8/2000 ($34.1M order/ $389M), Nov 6/06 ($127.4M order/ $506.1M), and Nov 27/06 ($28.8M order/ $534.9M).
USA: $7.1M for Antimicrobial Socks
Small business qualifier Special T Hosiery Mills, Inc. in Burlington, NC received a maximum $7.1 million firm fixed price contract for antimicrobial boot socks. Using services are the US Army, Air Force and Marine Corps. There were 25 proposals solicited, and 16 responded. The Defense Supply Center Philadelphia (DSCP) in Philadelphia, PA issued the contract, and the date of performance completion is April 7, 2009 (SP0100-05-D-0386).
The US Department of Commerce has an interesting report assessing the industrial base, and covering US military textile procurement from 1997-2002. Special T Hosiery lists as the contracts leader in its category ("Hosiery, Handwear, Clothing Accy").