text:
Research article
29 Jun 2012
Research article | 29 Jun 2012
Early and mid-Holocene climate in the tropical Pacific: seasonal cycle and interannual variability induced by insolation changes
Y. Luan et al.
Total article views: 3,982 (including HTML, PDF, and XML)Cumulative views and downloads (calculated since 01 Feb 2013, article published on 06 Feb 2012)Views and downloads (calculated since 01 Feb 2013, article published on 06 Feb 2012)
34 citations as recorded by crossref.
- Causes of Strengthening and Weakening of ENSO Amplitude under Global Warming in Four CMIP5 Models* L. Chen et al. 10.1175/JCLI-D-14-00439.1
- Precessional Forced Zonal Triple-Pole Anomalies in the Tropical Pacific Annual Cycle Y. Wang et al. 10.1175/JCLI-D-18-0668.1
- Greening of the Sahara suppressed ENSO activity during the mid-Holocene F. Pausata et al. 10.1038/ncomms16020
- Changes in the ENSO/SPCZ relationship from past to future climates M. Saint-Lu et al. 10.1016/j.epsl.2014.12.033
- Towards understanding the suppressed ENSO activity during mid-Holocene in PMIP2 and PMIP3 simulations L. Chen et al. 10.1007/s00382-019-04637-z
- Evidence for suppressed mid-Holocene northeastern Australian monsoon variability from coral luminescence J. Lough et al. 10.1002/2014PA002630
- Comparison of forced ENSO-like hydrological expressions in simulations of the preindustrial and mid-Holocene S. Lewis et al. 10.1002/2013JD020961
- Oxygen minimum zone variations in the tropical Pacific during the Holocene X. Xu et al. 10.1002/2015GL064680
- Holocene history of ENSO variance and asymmetry in the eastern tropical Pacific M. Carré et al. 10.1126/science.1252220
- The role of El Niño in the global energy redistribution: a case study in the mid-Holocene M. Saint-Lu et al. 10.1007/s00382-016-3266-5
- The Ensemble Oceanic Niño Index E. Webb & B. Magi 10.1002/joc.7535
- Drivers of reduced ENSO variability in mid-Holocene in a coupled model L. Chen et al. 10.1007/s00382-018-4496-5
- Comparison of past and future simulations of ENSO in CMIP5/PMIP3 and CMIP6/PMIP4 models J. Brown et al. 10.5194/cp-16-1777-2020
- Tropical Pacific mean state and ENSO changes: sensitivity to freshwater flux and remnant ice sheets at 9.5 ka BP Y. Luan et al. 10.1007/s00382-015-2467-7
- Decoupling of seasonal temperature and precipitation over the western Pacific during the early mid-Holocene W. Deng & G. Wei 10.1002/joc.4009
- High-resolution marine data and transient simulations support orbital forcing of ENSO amplitude since the mid-Holocene M. Carré et al. 10.1016/j.quascirev.2021.107125
- Causes of ENSO Weakening during the Mid-Holocene Z. Tian et al. 10.1175/JCLI-D-16-0899.1
- Evolution of Eastern Equatorial Pacific Seasonal and Interannual Variability in Response to Orbital Forcing During the Holocene and Eemian From Model Simulations V. Khon et al. 10.1029/2018GL079337
- Simulated Responses of the West African Monsoon and Zonal‐Mean Tropical Precipitation to Early Holocene Orbital Forcing J. Smyth et al. 10.1029/2018GL080494
- Improved ENSO simulation from climate system model FGOALS-g1.0 to FGOALS-g2 L. Chen et al. 10.1007/s00382-016-2988-8
- Links between tropical Pacific seasonal, interannual and orbital variability during the Holocene J. Emile-Geay et al. 10.1038/ngeo2608
- Mechanisms Reducing ENSO Amplitude and Asymmetry via an Enhanced Seasonal Cycle in the Mid-Holocene T. Iwakiri & M. Watanabe 10.1175/JCLI-D-19-0110.1
- Response of the Equatorial Pacific Seasonal Cycle to Orbital Forcing M. Erb et al. 10.1175/JCLI-D-15-0242.1
- Fine sediment mineralogy as a tracer of latest Quaternary sediment delivery to a dynamic continental margin: Pandora Trough, Gulf of Papua, Papua New Guinea A. Howell et al. 10.1016/j.margeo.2014.08.003
- High-resolution variability of the South American summer monsoon over the last seven millennia: insights from a speleothem record from the central Peruvian Andes L. Kanner et al. 10.1016/j.quascirev.2013.05.008
- Tropical cyclone genesis potential across palaeoclimates J. Koh & C. Brierley 10.5194/cp-11-1433-2015
- Impact of ENSO on East Asian winter monsoon during interglacial periods: effect of orbital forcing S. An et al. 10.1007/s00382-016-3506-8
- Heat budget analysis in three typical warm periods simulated by FGOALS-s2 Y. Luan et al. 10.1080/16742834.2015.1136781
- Statistical constraints on El Niño Southern Oscillation reconstructions using individual foraminifera: A sensitivity analysis K. Thirumalai et al. 10.1002/palo.20037
- Paleoenvironmental shifts and precipitation variations recorded in tropical maar lake sediments during the Holocene in Southern China X. Yang et al. 10.1177/0959683614540962
- Responses of Tropical Background State and ENSO Behaviors to Mid-Holocene Forcing Simulated by PMIP3 and PMIP4 Models M. Song & L. Chen 10.3389/feart.2022.853577
- Mid-Holocene sea surface conditions and riverine influence on the inshore Great Barrier Reef R. Roche et al. 10.1177/0959683614534739
- Precessional changes in the western equatorial Pacific Hydroclimate: A 240 kyr marine record from the Halmahera Sea, East Indonesia H. Dang et al. 10.1002/2014GC005550
- Mid-Holocene climate in New Caledonia (southwest Pacific): coral and PMIP models monthly resolved results C. Lazareth et al. 10.1016/j.quascirev.2013.02.024
Saved (final revised paper)
Saved (final revised paper)
Latest update: 09 Aug 2022


text:
This is the ninth facts sheet in several ten built to promote an overview of secret principles in-plant cystic. Bush cystic 's the study of bush situation such as the grounds as to the reasons vegetation get sick and how to manage or perform healthy flowers.
Some large plant versions go on the surface from otherwise parasitize almost every other flowers and frequently cause risky responses inside their hosts.
Epiphytes do-little or no injury to its servers vegetation, with them only having bodily assistance and safety. Advice was Spanish moss and you may epiphytic orchids, which in their local habitats commonly grow with the tree limbs.
Hemiparasites, often titled liquid parasitic organisms, create hurt their server vegetation, absorbing liquids and you may nutrient nutrients from their store. Yet not, they features chlorophyll and will make their particular carbs by the photosynthesis.
Witchweed (Striga asiatica) was a hemiparasitic vegetables bush one to honestly damages sugarcane, corn, sorghum, a great many other grasses, and several broad-leaved vegetation. It connects in itself towards the host's root and you may uses the majority of the newest host's liquid and you can mineral nourishment, resulting in they so you're able to wilt, purple, build badly and pass away. The best manage is to try to bush a harvest, like Sudan yard, you to definitely produces the fresh new witchweed seed products to germinate, upcoming plow in whole occupation. Vegetation should be turned and you will vulnerable crops shouldn't be rooted.
Mistletoe (Phoradendron spp.), other person in brand new hemiparasitic classification, periods of numerous large-leaved woods instance ash, silver maple, honeylocust, hackberry, cottonwood, walnut, pine, birch, sycamore and several conifers. The newest vegetables germinate with the branches from vulnerable servers, forming an attachment computer to the bark. New gluey fresh fruits are disseminated throughout the forest and you may out of tree in order to tree of the wild birds and you may cinch. Plain old handle, yet not very effective, sugar babies Las Vegas NV should be to cut out the brand new mistletoe twigs deep to your tree proximal to the level out of attachment. No good herbicidal manage was developed, though an inactive-year application of ethephon, an enthusiastic ethylene-establishing matter, is a viable manage with the particular plant life. An informed handle will be to plant only tree varieties resistant against mistletoe episodes.
True Parasitic organisms
Genuine parasites use up all your chlorophyll and you will rely on the machines for everyone nourishment-carbs, vitamins and you may water. Examples of this group may be the dwarf mistletoe (Arceuthobium spp.) and dodder (Cuscuta spp.). Broomrape (Orobanche spp.) is actually a critical parasitic insect for the Europe, Asia and Africa features triggered thorough problems for tomatoes within the Ca.
Dwarf mistletoe periods of a lot coniferous types regarding western All of us, cutting forest vitality and you will reducing lumber high quality. The brand new sticky vegetables (perhaps not this new fruit) was forcibly thrown and will travel to regarding the 19 yards (60 base). This is basically the principal technique of dissemination. Birds are known to carry the sticky vegetables on their feathers, but piece of cake plays a highly limited part from inside the dissemination. A knowledgeable control are removal of infected woods.
Dodder has many species, but throughout the six cause the biggest ruin, assaulting eg plants since the alfalfa, lespedeza, clover, flax, glucose beets, potatoes and many veggie vegetation and ornamentals. Dodder surely decrease output and you will quality of crops. Tight statutes prohibit new revenue from crop seeds contaminated of the dodder seed. High energy are going to be brought to prevent growing seed products that dodder vegetables blended with they. Patches off dodder during the field harvest otherwise along fences otherwise abandon finance companies shall be done away with by consuming or of the herbicides.
Here is the ninth fact sheet during the a few 10 made to bring an overview of trick basics in plant pathology. Bush pathology is the examination of bush disease like the grounds why herbs get sick and ways to control otherwise do healthy plant life.
To have more information on every of one's IPM actions, see the 4th facts layer in this series, "Staying Flowers Healthy: An overview of Integrated Plant Wellness Government" (PLPATH-GEN-4).

subset: commoncrawl


text:
Emerson, a global provider of industrial automation technology and software, has announced a framework agreement with paint manufacturer Jotun to automate and digitalise its global manufacturing facilities.
The five-year agreement will enable Jotun, which manufactures decorative paints and marine, protective and powder coatings, to implement Emerson's digital technologies to enhance all aspects of manufacturing automation in new factories, and for selected upgrades in some of its 39 existing factories around the world.
Through its agreement with Emerson, Jotun will increase process automation and create a standardised digital technology solution for new factory projects, which will reportedly help the company achieve increased throughput, uptime and product quality, while reducing operating costs.
"In securing a long-term automation partner with the expertise required to support our journey, we will have access to systems, competence and support serving our needs when constructing and operating technically advanced and efficient paint factories around the world," said Fredrik Urdahl, Jotun's group technical director – operations.
"Emerson's advanced automation technologies and focus on providing standardised project methodologies, as well as global and local support, were critical factors in our selection for collaboration."
Jotun will initially focus on standardising on Emerson's DeltaV distributed control system in new factory projects. According to Emerson, the intelligent control will ensure consistent, integrated batch processes, minimising risk to product quality and enhancing productivity.
The agreement also enables Emerson to deliver a wide range of automation solutions to improve Jotun's manufacturing operations. These could include advanced sensor technologies, data management and analytics platforms, software applications, predictive maintenance and remote monitoring techniques and asset management tools.


text: Home » Candidate Online Assessment » Numerical Reasoning June21Numerical Reasoning June21by email@example.com 24, 2021 Welcome to the second section of the LURA Online Assessment Centre. This section will test your numerical reasoning. Please read all instructions before starting. You will be presented with two scenarios, each accompanied with some data in a chart or a graph, and then asked four numerical questions on each scenario, which will require you to interpret and manipulate the data. It is recommended that you use a calculator. Each correct answer will gain you 1 point and each incorrect answer will gain you 0 points. There are 8 questions in total, thus your final score will therefore be out of 8. Before you answer any questions, please ensure you have filled out your name and UoL Identifier at the top of the test page. Once you have answered all questions, press SUBMIT at the bottom of the page. You have 10 minutes to complete the test. A timer is displayed both at the top of this page and in the title of the tab on your browser. If you have not finished the test when the timer runs out, any questions you have answered will be marked and any questions you have not answered will be given 0 marks. LURA will only receive your first attempt at the test. Any further attempts will not count. Thinking of cheating? We have in-built methods that detect if candidates cheat on these assessments. Naturally, if we suspect you have cheated during any part of this process, your application will be declined. Something not working? Call 07917401722 urgently. First and Surname UoL Identifier (e.g. mn18az) Scenario 1 Figure 1a shows how the budget for an aerospace company was split between the company's departments in 2020. Figure 1b shows how the R&D budget was then split between the three projects the company is developing. The total company budget in 2020 came to £640,000. Scenario 1: Question 1What is the total monetary value of the Sales and Marketing budgets together to the nearest £10,000? £130,000 £210,000 £200,000 £150,000 Scenario 1: Question 2 How much did the company spend on Aircraft R&D in 2020 to the nearest £5,000? £110,000 £170,000 £55,000 £80,000 Scenario 1: Question 3 Figure 2a shows how the budget for the same aerospace company was split between the departments the subsequent year, in 2021. Figure 2b shows how the R&D budget was then split between the three projects the company is developing.The company spent £70,000 on Marketing in 2021. How much did they spend on Spacecraft R&D to the nearest £10,000 in 2021? £50,000 £150,000 £80,000 £130,000 Scenario 1: Question 4 How much more did the company spend on Sales in 2021 compared to 2020 to the nearest £10,000? £10,000 £20,000 £30,000 £40,000 Scenario 2 Figure 3 shows the number of signups, to the nearest 10, for three different university clubs across four consecutive months.Scenario 2: Question 1What percentage of Club B signups occurred in October? (to the nearest 1%) 20% 24% 31% 27% Scenario 2: Question 2 What percentage of total signups in December were for Club C? (to the nearest 1%) 27% 29% 32% 39% Scenario 2: Question 3 Which of the three clubs had the highest number of signups across the period shown? Club A Club B Club C Scenario 2: Question 4 When did the largest percentage increase in cumulative signups for Club A occur? Sept - Oct Oct - Nov Nov - Dec


text:
7 Tips for Making Photo Books
Making photo books is one of our favorite things to do – for ourselves and our clients. If you like to cook, you understand the
Making photo books is one of our favorite things to do – for ourselves and our clients. If you like to cook, you understand the
Print photo preservation is often overlooked. Today, we shoot digital photos, thanks to our sophisticated smart phones. But print photos are still a large part
September is Save Your Photos month! I often think of what author Gretchen Rubin says about this time of year: "September is the other January.
Let's talk about saving your photos; syncing vs backups. When I ask my friends, family, and clients if they sync and/or back up their photos,
Here's a quick look at how a print-to-digital family photos organizing job is handled. (our client, Marie, has permitted us to share her family photos
A legacy photo collection is a little different from the photos you have of family vacations, weddings, birthdays, and everyday life. But before getting into
As a professional photo organizer, I've noticed the opportunities for holiday photos have grown. As soon as Labor Day is over, it's harvest time and
Let's talk back-up for your photo collection. Do you back-up your photos on a regular basis? If not, I'll let you in on a photo
If you are like most people, you have digital photos. A lot of them. And you want them organized. What if you aren't sold on
Do you want to make a photo book but aren't sure how? Are you wondering what images from your collection to use? Are you unsure


text:
Duma Collective is the new lead creative communications agency for the MultiChoice Group. It will oversee public relations and social media for DStv, General Entertainment channels, and the group's corporate brand.
The 100% black female-owned creative communications agency services FMCG brands, event production companies, performing talent as well as government departments in South Africa and the rest of Africa. It was one of the eight MultiChoice Innovation Fund beneficiaries of 2020.
"Duma Collective has earned its place as a premier creative communications agency," said Joe Heshu, MultiChoice group executive for corporate affairs. "It is a young agency that pushes the envelope and is closest to the pulse of South Africa's creative industry. They are a natural fit in ensuring our platforms continue being the voice of South Africa's ingenious industry."
MultiChoice said the appointment continued its commitment to scale and ensured the development of Duma Collective in awarding them this contract.
"MultiChoice looks to investing in businesses like Duma Collective because they want to be part of the solution," said Duma Collective director, Sibu Mabena. "They recognise that we are trying our best to contribute to the economy and contribute to the growth of our country, and they want to be part of that. It's been a crazy experience seeing us go from a small boutique agency to this formidable creative communications firm and MultiChoice has been a catalyst in getting us here."
Duma Collective has been a MultiChoice Group service provider since 2019, having worked on campaigns such as the DStv Showcase, Phuthuma Nathi, DStv Premiership, new show launches for M-Net, Showmax, as well as the recent and highly recognised Channel O's Lockdown House Party.
As a young, agile and innovative agency with a passion for creative communications achieved through public relations, events, social media, brand strategy, and multimedia design, Duma Collective's work has garnered a reputable track record with a client list of local brands such as Drip Footwear, Cassper Nyovest's Fill Up Series, Black Coffee's Music Is King, SAFTAs, SAMAs, and Showmax along with global brands such as Chivas, Red Bull, VIACOM, Global Citizen, Afropunk and Samsung to name but a few.
Want to continue this conversation on The Media Online platforms? Comment on Twitter @MediaTMO or on our Facebook page. Send us your suggestions, comments, contributions or tip-offs via e-mail to email@example.com.


text:
| 2003
Diary takes the form of a 'coma diary' kept by one Misty Tracy Wilmot as her husband lies senseless in hospital after a suicide attempt. But then, as if possessed by the spirit of Maura Kinkaid, a fabled Waytansea artist of the nineteenth century, Misty begins painting again, compulsively.
Visa mer
Bli först med att recensera denna bok


text:
Varied and innovative technical and educational resources
The Medical Simulation Center has training spaces equipped with technology for transmitting and sharing simulation sessions, as well as high-fidelity equipment: mannequins and simulators allowing training in emergency procedures and gestures.
Both professionals and students can acquire and update their skills as well as good practices in the disciplines taught.
Our target audience
- Doctors
- Paramedics
- Health trainers
- Residents
- Rescuers
- Individuals
- Interns
- Ambulances
Ours Goals
- Create or make available training tools
- Provide methodological support and assistance
- Provide equipment related to specific simulation techniques
- (high-fidelity mannequin, delivery basin, infusion arm)
- Develop research projects
- Carry out national and international communication actions (publications, congresses)
- Be a reference center for certain types of simulation
- Assessment of learners' learning in terms of knowledge, skills and attitudes acquired
Develop research projects
It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout.


text:
Join Mark Barrow from "Beneath British Waters" at the historic Withy Pool fishery for a study of the resident big Catfish in their element!
Related Posts
Commercial match fishing tactics and tips
April 10, 2020
Testing Groundbaits Underwater!
February 25, 2022
Winter Barbel Fishing Pt2
December 16, 2020
Monster Sturgeon with Carl & Alex
May 7, 2020
Recent Posts
Recent Comments
- Michael Hall on Salmon Fishing | Induced Takes
- christopher jones on Blast from the Past: King Fisher (1968) featuring match angling legend Ray Mumford
- Leamington Angling Newsletter April 2020 | Leamington Angling on My Life in Angling: Interview with Ian Heaps
- John Cheyne on Fisheries management during coronavirus pandemic
- TERRY BOYLING on Fisheries management during coronavirus pandemic


text:
Category: Critical Care
Keywords: cardiac arrest, CPR, cardiopulmonary resuscitation, hands-off time, CCF, chest compression fraction (PubMed Search)
Posted: 7/6/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
Despite the knowledge that minimizing interruptions in chest compressions during CPR is key to maintaing coronary perfusion pressure and chance of ROSC,1-4 difficulties in limiting hands-off time remain.
Dewolf et al.5 recently performed a prospective observational study using body cameras to find that 33% (623/1867) of their CPR interruptions were longer than the recommended 10 seconds:
Previous studies have shown an increase in hands-off time associated with the use of cardiac POCUS during rhythm checks as well.6,7
Bottom Line:
Category: Critical Care
Keywords: OHCA, hypothermia, normothermia (PubMed Search)
Posted: 6/29/2021 by Quincy Tran, MD
(Updated: 8/17/2022)
Click here to contact Quincy Tran, MD
Settings: International multicenter trials; 1:1 randomization, blinded assessment of outcomes.
Patients: adults with witnessed OHCA, regardless of initial rhythm. Patients had more than 20 minutes of CPR. Eligible patients were unconscious, not able to follow command, no verbal responses to painful stimuli.
Intervention: hypothermia to target of 33C for 28 hours, then rewarming at rate of 1/3C every hour until 37C.
Comparison: maintaining temperature at 37.5C or less. Cooling if body temperature reached 37.8C to 37.5C
Outcome: primary outcome was Any cause mortality at 6 months; secondary outcome was poor functional outcome at 6 months (modified Rankin Scale 4-6).
Study Results:
1. 930 hypothermia, mortality 465/925 (50%, RR 1.04, 95%CI 0.94-1.14); 488/881 (55%) had mRS 4-6 (RR 1.0, 95%CI 0.92-1.09).
2. 931 normothermia, mortality 446/925 (48%); 479/866 (55%) had mRS 4-6.
Discussion Points:
Normothermia in coma patients after OHCA did not lead to higher morality or worse neurologic outcomes.
Dankiewicz J, Cronberg T, Lilja G, Jakobsen JC, Levin H, Ullén S, Rylander C, Wise MP, Oddo M, Cariou A, B?lohlávek J, Hovdenes J, Saxena M, Kirkegaard H, Young PJ, Pelosi P, Storm C, Taccone FS, Joannidis M, Callaway C, Eastwood GM, Morgan MPG, Nordberg P, Erlinge D, Nichol AD, Chew MS, Hollenberg J, Thomas M, Bewley J, Sweet K, Grejs AM, Christensen S, Haenggi M, Levis A, Lundin A, Düring J, Schmidbauer S, Keeble TR, Karamasis GV, Schrag C, Faessler E, Smid O, Otáhal M, Maggiorini M, Wendel Garcia PD, Jaubert P, Cole JM, Solar M, Borgquist O, Leithner C, Abed-Maillard S, Navarra L, Annborn M, Undén J, Brunetti I, Awad A, McGuigan P, Bjørkholt Olsen R, Cassina T, Vignon P, Langeland H, Lange T, Friberg H, Nielsen N; TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021 Jun 17;384(24):2283-2294. doi: 10.1056/NEJMoa2100591. PMID: 34133859.
Category: Critical Care
Keywords: cardiac arrest, ROSC, computed tomography, CT scan, imaging (PubMed Search)
Posted: 6/16/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
A recent prospective observational study examined the diagnostic usefulness of head-to-pelvis sudden death computed tomography (SDCT) in 104 patients with ROSC and unclear OHCA etiology.
Diagnostic performance:
Bottom Line: For OHCA without clear etiology, SDCT explicitly including a thoracic CTA may have diagnostic benefit over standard care alone with the added benefit of identification of resuscitation complications.
Branch KRH, Strote J, Gunn M, et al. Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology. Acad Emerg Med. 2021 Apr;28(4):394-403. doi: 10.1111/acem.14228.
Category: Critical Care
Keywords: midodrine; septic shock; vasopressors; ICU LOS (PubMed Search)
Posted: 6/8/2021 by Kim Boswell, MD
Click here to contact Kim Boswell, MD
A recent pilot study was conducted in two centers (Mayo Clinic & Cleveland Clinic Affiliate) and aimed to evaluate if the administration of oral midodrine in early septic shock could decrease the use of IV vasopressors and decrease ICU and hospital length of stay (LOS). The study was a placebo-controlled, double blinded randomized trial.
This study enrolled:
The study did not find a statistical difference between the two groups in the use of vasopressors or ICU/Hospital LOS. However, there was a trend in the midodrine group which is suggestive of decreased vasopressor use and ICU/Hospital LOS.
It is Important to note the study was not powered to determine clinical significance. Overall the trend noted in the midodrine group should encourage further studies that are clinically powered to determine if there is a statistical difference and therefore a potential benefit to early initiation of oral midodrine in septic shock.
Lal, A, Trivedi, V, Rizvi, MS, et al. Oral Midodrine Administration During the First 24 Hours of Sepsis to Reduce the Need of Vasoactive Agents: Placebo-Controlled Feasibility Clinical Trial, Critical Care Explorations: May 2021 - Volume 3 - Issue 5 - p e0382
doi: 10.1097/CCE.0000000000000382
Category: Critical Care
Keywords: Pressors, Vasopressin, Sepsis, Septic Shock (PubMed Search)
Posted: 5/31/2021 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD
Norepinephrine is widely considered the first-line vasopressor for patients in septic shock. Vasopressin is often added to norepinephrine in patients requiring escalating doses, but when to add vasopressin, and what exactly the benefit is (as opposed to just further titrating up the norepinephrine) remain unclear. Given the limited evidence for a patient-oriented benefit and the increasing cost of vasopressin, some centers are becoming more judicious in the use of vasopressin. A systematic review in AJEM October 2021 examined the literature on early (< 6 hours of diagnosis) addition of vasopressin to the management of septic shock patients, compared to either no vasopressin or starting it after 6 hours.
Improved with early vasopressin: Need for renal replacement therapy (RRT; secondary outcome)
No difference: mortality, ICU length of stay, hospital length of stay, new onset arrhythmias
Bottom Line: When, and if, to start vasopressin in patients requiring escalating doses of norepinephrine remains controversial. Based on the prior VASST trial, many providers will start vasopressin when norepi doses reach ~ 5-15 mcg/min (approx 0.1-0.2 mcg/kg/min), but there remains limited data to support this practice, and either starting vasopressin or continuing to titrate the norepinephrine as needed are both reasonable approaches in most patients.
1) Huang H, Wu C, Shen Q, Xu H, Fang Y, Mao W. The effect of early vasopressin use on patients with septic shock: A systematic review and meta-analysis. Am J Emerg Med. 2021 May 6;48:203-208. doi: 10.1016/j.ajem.2021.05.007. Epub ahead of print. PMID: 33975132.
2) Russell JA, Walley KR, Singer J, Gordon AC, Hébert PC, Cooper DJ, Holmes CL, Mehta S, Granton JT, Storms MM, Cook DJ, Presneill JJ, Ayers D; VASST Investigators. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008 Feb 28;358(9):877-87. doi: 10.1056/NEJMoa067373. PMID: 18305265.
3) Lam SW, Barreto EF, Scott R, Kashani KB, Khanna AK, Bauer SR. Cost-effectiveness of second-line vasopressors for the treatment of septic shock. J Crit Care. 2020 Feb;55:48-55. doi: 10.1016/j.jcrc.2019.10.005. Epub 2019 Oct 23. PMID: 31706118.
Category: Critical Care
Posted: 5/25/2021 by Mike Winters, MD
Click here to contact Mike Winters, MD
Refractory Anaphylaxis
Krishnaswamy G. Critical care management of anaphylaxis: A conside definitive review. Crit Care Med. 2021.
Category: Critical Care
Keywords: COVID-19, tocilizumab, ICU, mechanical ventilation (PubMed Search)
Posted: 5/11/2021 by Lindsay Ritter, MD
(Updated: 8/17/2022)
Click here to contact Lindsay Ritter, MD
RECAP: RECOVERY trial is a large, randomized, open label, adaptive trial studying different treatments on COVID-19. Most well known is the use of dexamethasone which reduced mortality by 1/3 in COVID patients requiring mechanical ventilation and by 1/5 in those requiring oxygen, with no benefit on those patients not requiring oxygen.
They recently published results in the Lancet on the use of tocilizumab.
RECOVERY Collaborative Group Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet. 2021; 397: 1637-1645
Category: Critical Care
Keywords: cardiac arrest, massive pulmonary embolism, Venoarterial, ECMO (PubMed Search)
Posted: 5/4/2021 by Quincy Tran, MD
(Updated: 8/17/2022)
Click here to contact Quincy Tran, MD
Cardiac arrest from massive pulmonary embolism (PE) can be up to 90% (1). A recent systemic review evaluated the efficacy of Venoarterial-Extracorporeal Membrane Oxygenation (VA-ECMO) for PE-related cardiac arrest.
The authors screened 1115 articles and included 77 articles, including gray literature. The authors performed a quantitative analysis of a total of 301 patients.
Overall, 183/301 (61%) patients survived to hospital discharge, a significant improvement from 90%.
Patients who were cannulated during chest compression were associated with 7x higher odds of death (OR, 6.84; 95% CI, 1.53–30.58; p = 0.01), compared to those who were cannulated after ROSC. However, cannulation in the ED was not associated with improved outcomes, compared with other cannulation site.
No increased risk of death among patients who received tPA prior to VA-ECMO vs. those who did not (OR, 0.78; 95% CI, 0.39–1.54; p = 0.48).
Patients whose age > 65 years of age were associated with 3X risk of death, compared to those with age < 65 years (OR, 3.56; 95% CI, 1.29–9.87; p = 0.02).
Take-home points
Please consider "early" VA-ECMO for eligible patients who have cardiac arrest from massive PE. However, it will take great convincing to push the PERT team to cannulate for VA-ECMO while the patient is still receiving chest compression.
1.Lavonas EJ, Drennan IR, Gabrielli A, et al: Part 10: Special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015; 132:S501–S518.
2. Scott JH, Gordon M, Vender R, Pettigrew S, Desai P, Marchetti N, Mamary AJ, Panaro J, Cohen G, Bashir R, Lakhter V, Roth S, Zhao H, Toyoda Y, Criner G, Moores L, Rali P. Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review. Crit Care Med. 2021 May 1;49(5):760-769. doi: 10.1097/CCM.0000000000004828. PMID: 33590996.
Category: Critical Care
Keywords: cardiac arrest, massive pulmonary embolism, Venoarterial, ECMO (PubMed Search)
Posted: 5/4/2021 by Quincy Tran, MD
Click here to contact Quincy Tran, MD
Cardiac arrest from massive pulmonary embolism (PE) can be up to 90% (1). A recent systemic review evaluated the efficacy of Venoarterial-Extracorporeal Membrane Oxygenation (VA-ECMO) for PE-related cardiac arrest.
The authors screened 1115 articles and included 77 articles, including gray literature. The authors performed a quantitative analysis of a total of 301 patients.
Overall, 183/301 (61%) patients survived to hospital discharge, a significant improvement from 90%.
Patients who were cannulated during chest compression were associated with 7x higher odds of death (OR, 6.84; 95% CI, 1.53–30.58; p = 0.01), compared to those who were cannulated after ROSC. However, cannulation in the ED was not associated with improved outcomes, compared with other cannulation sites.
No increased risk of death among patients who received tPA prior to VA-ECMO vs. those who did not (OR, 0.78; 95% CI, 0.39–1.54; p = 0.48).
Patients whose age > 65 years of age were associated with 3X risk of death, compared to those with age < 65 years (OR, 3.56; 95% CI, 1.29–9.87; p = 0.02).
Take-home points
Please consider "early" VA-ECMO for eligible patients who have cardiac arrest from massive PE. However, it will take great convincing to push the PERT team to cannulate for VA-ECMO while the patient is still receiving chest compression.
1.Lavonas EJ, Drennan IR, Gabrielli A, et al: Part 10: Special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015; 132:S501–S518.
2. Scott JH, Gordon M, Vender R, Pettigrew S, Desai P, Marchetti N, Mamary AJ, Panaro J, Cohen G, Bashir R, Lakhter V, Roth S, Zhao H, Toyoda Y, Criner G, Moores L, Rali P. Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review. Crit Care Med. 2021 May 1;49(5):760-769. doi: 10.1097/CCM.0000000000004828. PMID: 33590996
Category: Critical Care
Keywords: COPD, emphysema, acute respiratory failure, hypoxia, oxygen saturation (PubMed Search)
Posted: 4/20/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
Supplemental oxygen therapy is frequently required for patients presenting with acute respiratory distress and COPD exacerbation. Over-oxygenation can derail compensatory physiologic responses to hypoxia,1 resulting in worsening VQ mismatch and, to a lesser degree, decreases in minute ventilation, that cause worsened respiratory failure.
The 2012 DECAF (Dyspnea, Eosinopenia, Consolidation, Acidaemia, and Atrial Fibrillation) score was found to predict risk of in-hospital mortality in patients admitted with acute COPD exacerbation.2,3 Data from the DECAF study's derivation and external validation cohorts were examined specifically to look at outcome associated with varying levels of oxygen saturation.
Bottom Line
In patients presenting to the ED with acute COPD exacerbation requiring oxygen supplementation, a target oxygen saturation of 88-92% is associated with the lowest in-hospital mortality, and higher oxygen saturations should be avoided independent of patients' PCO2 levels.
Category: Critical Care
Keywords: COVID-19, Anticoagulation, Thromboembolism (PubMed Search)
Posted: 4/7/2021 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD
Two items from the recent INSPIRATION trial UMEM pearl were very well pointed out by our own Dr. Michael Scott and require clarification. Thank you to all our readers for their close attention, and please know that we always appreciate you reaching out with questions/comments.
Category: Critical Care
Keywords: COVID-19, Anticoagulation, Thromboembolism (PubMed Search)
Posted: 4/7/2021 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD
COVID-19 is generally regarded as a hypercoagulable state, and the role of pulmonary emboli and other VTE in COVID remains unclear. As a result, how to optimally provide prophylactic anticoagulation in COVID-19 patients who are not known to have VTE has been a point of debate.
The INSPIRATION trial looked at 600 patients admitted to academic ICUs in Iran, and compared what is often-referred to as "intermediate-dose" prophylaxis (in this case 1 mg/kg daily of enoxaparin) to standard dose prophylaxis (40 mg/day of enoxaparin). The study utilized a combined endpoint of venous thromboembolism, arterial thromboembolism, need for ECMO, or mortality. As a reminder, composite endpoints can skew results. However, the dose and type of anticoagulant chosen is similar to many academic centers around the world, and pharmacy guidelines often recommend providing this type of "intermediate-dose" prophylaxis in COVID-19 patients, sometimes based on clinical status, d-dimer or other coagulation-related patient-data. As with many things with COVID-19, this practice is based on limited data.
There was no significant difference between groups in the primary outcome (45.7% in intermediate ppx group vs 44.1% in standard group), and while safety outcomes were similar (major bleeding in 2.5% in the intermediate ppx group vs 1.4% in standard group), the intermediate regimen failed to demonstrate non-inferiority to the standard regimen for major bleeding.
Intermediate vs standard-dose ppx was similar in this study with a small, but statistically significant increase in major bleeding in the intermediate-dose group.
Bottom Line: Although this study had methodologic flaws and there are external validity concerns, the INSPIRATION trial supports the notion that standard dose (e.g. 40 mg/g/kg/day enoxaparin) and intermediate-dose (e.g. 1 mg/kg/day enoxaparin) VTE prophylaxis are equivalent in critically ill COVID-19 patients who do not already have a known VTE in terms of preventing negative VTE outcomes. Intermediate-dose may be associated with increased bleeding. As more critically ill patients require ED boarding, the dose of VTE prophylaxis may remain controversial, but the need to start it remains an important consideration.
INSPIRATION Investigators, Sadeghipour P, Talasaz AH, Rashidi F, Sharif-Kashani B, Beigmohammadi MT, Farrokhpour M, Sezavar SH, Payandemehr P, Dabbagh A, Moghadam KG, Jamalkhani S, Khalili H, Yadollahzadeh M, Riahi T, Rezaeifar P, Tahamtan O, Matin S, Abedini A, Lookzadeh S, Rahmani H, Zoghi E, Mohammadi K, Sadeghipour P, Abri H, Tabrizi S, Mousavian SM, Shahmirzaei S, Bakhshandeh H, Amin A, Rafiee F, Baghizadeh E, Mohebbi B, Parhizgar SE, Aliannejad R, Eslami V, Kashefizadeh A, Kakavand H, Hosseini SH, Shafaghi S, Ghazi SF, Najafi A, Jimenez D, Gupta A, Madhavan MV, Sethi SS, Parikh SA, Monreal M, Hadavand N, Hajighasemi A, Maleki M, Sadeghian S, Piazza G, Kirtane AJ, Van Tassell BW, Dobesh PP, Stone GW, Lip GYH, Krumholz HM, Goldhaber SZ, Bikdeli B. Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality Among Patients With COVID-19 Admitted to the Intensive Care Unit: The INSPIRATION Randomized Clinical Trial. JAMA. 2021 Mar 18. doi: 10.1001/jama.2021.4152. Epub ahead of print. PMID: 33734299.
Category: Critical Care
Posted: 3/30/2021 by Mike Winters, MD
Click here to contact Mike Winters, MD
Improving Compliance with Lung-Protective Ventilation
Tallman CMI, et al. Impact of provding a tape measure on the provision of lung-protective ventilation. West J Emerg Med. 2021; 22:389-93.
Category: Critical Care
Posted: 3/16/2021 by Lindsay Ritter, MD
Click here to contact Lindsay Ritter, MD
The PARAMEDIC2 trial in NEJM 2018 studied the outcomes of the use of epinephrine in outside hospital cardiac arrest (OHCA) on survival and neurological outcome.
Methods: Conducted in Britain, randomized 8007 patients to receive either epinepherine 1mg (n=4012) or placebo (n=3995) as part of standard CPR for out-of-hosptial arrest. Their primary outcome was survival at 30 days and their secondary outcomes included length of stay as well as neurological outcomes at 30 days and 3 months.
Results: The epinepherine group had improved survival to hospital admission (23% vs. 8%), at 30 days (3.2% vs. 2.4%) or at 3 months (3% vs. 2.2%). Favourable neurological outcomes, however, had no statistical difference at both hospital discharge and at 3 months.
Bottom line: Epinephrine improves ROSC, though with poor neurological outcomes.
Important facts:
Recently, a follow up of the PARAMEDIC2 trial was completed in Resuscitation.
They reported long-term survival, quality of life, functional and cognitive outcomes at 3, 6 and 12-months.
Results: At 6 months, 78 (2.0%) of the patients in the adrenaline group and 58 (1.5%) of patients in the placebo group had a favourable neurological outcome (adjusted odds ratio 1.35 [95% confidence interval: 0.93, 1.97]). 117 (2.9%) patients were alive at 6-months in the adrenaline group compared with 86 (2.2%) in the placebo group (1.43 [1.05, 1.96], reducing to 107 (2.7%) and 80 (2.0%) respectively at 12-months (1.38 [1.00, 1.92]). Measures of 3 and 6-month cognitive, functional and quality of life outcomes were reduced, but there was no strong evidence of differences between groups.
Bottom line: Epinephrine improves survival at 12 months, but poor neurological outcomes remain.
Haywood KL, Ji C, Quinn T, Nolan JP, Deakin CD, Scomparin C, Lall R, Gates S, Long J, Regan S, Fothergill RT, Pocock H, Rees N, O'Shea L, Perkins GD. Long term outcomes of participants in the PARAMEDIC2 randomised trial of adrenaline in out-of-hospital cardiac arrest. Resuscitation. 2021 Mar;160:84-93. doi: 10.1016/j.resuscitation.2021.01.019. Epub 2021 Jan 30. PMID: 33524488.
Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O'Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R; PARAMEDIC2 Collaborators. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18. PMID: 30021076.
Category: Critical Care
Keywords: sepsis recognition, antibiotics administration, mortality, (PubMed Search)
Posted: 3/10/2021 by Quincy Tran, MD
(Updated: 8/17/2022)
Click here to contact Quincy Tran, MD
The association between time intervals of ED antibiotic administration and outcome has been controversial. While single studies showed there was increased mortality associated with delayed antibiotic administration (1-3). A meta-analysis of 13 studies and 33000 patients showed that there was no mortality difference between septic patients receiving immediate Abx (< 1 hour) vs. those receiving early abx (1-3 hours) (4).
Since delay in recognition of sepsis (defined as ED triage to Abx order) and delay in antibiotics delivery (Abx order to administration) contribute to total delay of Abx administration, a new retrospective study (3) attempted to investigate the contributions of either factor to hospital mortality.
The study used generalized linear mixed models and involved 24000 patients.
For All patients and outcome of hospital mortality:
Recognition delay (ED triage to Abx order): OR 2.7 (95% CI 1.5-4.7)*
Administration delay at 2-2.5 hours (Abx order to administration): OR 1.5 (1.1-2.0)
These results was associated with non-statistical significance in patients with septic shocks.
Delayed recognition of sepsis was associated with higher hospital mortality. Longer delay of abx administration was also associated with increased risk of hospital mortality.
1.Kumar A, Roberts D, Wood KE, et al: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006; 34:1589–1596
2. Ferrer R, Martin-Loeches I, Phillips G, et al: Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: Results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749–1755
3. Seymour CW, Gesten F, Prescott HC, et al: Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med 2017; 376:2235–2244.
4. Rothrock SG et al. Outcome of immediate versus early antibiotics in severe sepsis and septic shock: A systematic review and meta-analysis. Ann Emerg Med 2020 Jun 24; [e-pub]. (https://doi.org/10.1016/j.annemergmed.2020.04.042)
Category: Critical Care
Posted: 3/2/2021 by Caleb Chan, MD
(Updated: 8/17/2022)
Click here to contact Caleb Chan, MD
Clinical Question:
Take-home points:
Hughes CG, Mailloux PT, Devlin JW, et al. Dexmedetomidine or propofol for sedation in mechanically ventilated adults with sepsis. N Engl J Med. Published online February 2, 2021:NEJMoa2024922.
Category: Critical Care
Keywords: HACOR, NIV, noninvasive ventilation, acute respiratory failure (PubMed Search)
Posted: 2/2/2021 by Kami Windsor, MD
(Emailed: 2/23/2021)
(Updated: 2/23/2021)
Click here to contact Kami Windsor, MD
Background: In respiratory failure due to COPD and cardiogenic pulmonary edema, noninvasive positive pressure ventilation decreases need for intubation and improves mortality,1 while its utility in other scenarios such as ARDS and pneumonia has yet to be proven.1,2 We know that patients on NIV with delays to needed intubation have a higher mortality,1,3 but intubation and mechanical ventilation come with risks that it is preferable to avoid if possible.
So how and when can we determine that NIV is not working?
The HACOR (Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate) score at 1 hour after NIV initiation has been demonstrated to be highly predictive of NIV failure requiring intubation.4,5
Initial development/validation: Score > 5 after 1 hour of NIV corresponds to >80% risk of NIV failure4
Earlier intubation (before 12 hours) in these patients = better survival
External validation: Score > 8 after 1 hour of NIV most predictive of eventual NIV failure 5
Average score @ 1-hour of patients with NIV success = 3.8
Score remained predictive at 6, 12, 24, 48 hours as well & mortality worsened as delay to intubation time increased
Baseline, pre-NIV score not predictive
Better predictive agreement in pneumonia and ARDS
Bottom Line:
Patients on NIV require close reassessment to prevent worsened survival due to intubation delay should invasive mechanical ventilation be indicated.
A HACOR score >8 after 1 hour of NIV should prompt intubation in most instances, with strong consideration given to a score >5.
*Note: ABGs were obtained for PaO2 assessment in the above studies -- the use of SpO2 was not evaluated -- but we are often not obtaining ABGs in our ED patients with acute respiratory failure. The following chart provides an estimated SpO2 to PaO2 conversion.
Category: Critical Care
Keywords: Oxygenation, Mechanical Ventilation, Critical Care (PubMed Search)
Posted: 2/9/2021 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD
Optimal oxygenation targets and the possible, theoretical, benefits of hyperoxygenating critically ill patients have long been points of controversy. Multiple studies have suggested harm in pursuing aggressive hyperoxygenation amongst critical patients with various conditions ranging from myocardial infarction to sepsis to neurologic conditions. In addition, oxygen toxicity is a known mechanism causing ARDS.
The HOT-ICU trial adds to the list of arguments against hyperoxygenation, by looking at 2928 ICU patients on high levels of supplemental oxygen and targeting a paO2 of 60 mm Hg (low oxygen group) vs paO2 of 90 mm Hg (high oxygen group). There was no difference in mortality, or other significant difference in outcomes.
Bottom Line: A lower paO2 goal of 60 (correlates to an O2 sat of 90%) is noninferior to a higher paO2 goal of 90 (O2 sat of approximately 96%). When titrating oxygen, targeting a pulse ox of 90-96% is reasonable in critically ill patients. Be sure to include an upper limit on the sat goal, beware an O2 sat of 100%, and titrate down supplemental oxygen when the spO2 is above goal, as the paO2 may be dangerously high.
Schjørring OL, Klitgaard TL, Perner A, Wetterslev J, Lange T, Siegemund M, Bäcklund M, Keus F, Laake JH, Morgan M, Thormar KM, Rosborg SA, Bisgaard J, Erntgaard AES, Lynnerup AH, Pedersen RL, Crescioli E, Gielstrup TC, Behzadi MT, Poulsen LM, Estrup S, Laigaard JP, Andersen C, Mortensen CB, Brand BA, White J, Jarnvig IL, Møller MH, Quist L, Bestle MH, Schønemann-Lund M, Kamper MK, Hindborg M, Hollinger A, Gebhard CE, Zellweger N, Meyhoff CS, Hjort M, Bech LK, Grøfte T, Bundgaard H, Østergaard LHM, Thyø MA, Hildebrandt T, Uslu B, Sølling CG, Møller-Nielsen N, Brøchner AC, Borup M, Okkonen M, Dieperink W, Pedersen UG, Andreasen AS, Buus L, Aslam TN, Winding RR, Schefold JC, Thorup SB, Iversen SA, Engstrøm J, Kjær MN, Rasmussen BS; HOT-ICU Investigators. Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure. N Engl J Med. 2021 Jan 20. doi: 10.1056/NEJMoa2032510. Epub ahead of print. PMID: 33471452.
Category: Critical Care
Posted: 2/2/2021 by Mike Winters, MD
(Updated: 8/17/2022)
Click here to contact Mike Winters, MD
Mechanical Ventilation in COPD
Demoule A, et al. How to ventilate obstructive and asthmatic patients. Intensive Care Med. 2020; 46:2436-2449.
Category: Critical Care
Posted: 1/19/2021 by Lindsay Ritter, MD
Click here to contact Lindsay Ritter, MD
Ever wonder what to tell the families regarding prognosis of the sickest COVID-19 patients you intubate in the ED or ICU?
Introduction: Case fatality rates (CFR) for COVID-19 patients requiring invasive mechanical ventilation have been widely variable. A study in the Blue Journal (AJRCCM) examined patients requiring intubation in a systemic review and meta-analysis.
The case fatality risk of an infection is represented by the proportion of patients who die among all infected cases in a population over a period of time.
Methods: 69 studies axross 23 countries for a total of 57,420 patients with COVID-19 who required mechanical ventilation were included in analysis.
Results: Overall case fatality rate was 45%, or about 1 death for every two intubated patients.. Among studies that included age stratification, pooled estimates of CFR were 47.9% in patients <40 (CI 46.4-49.4%) and 84.4% in patients >80 (CI 83.3-85.4%). Overall heterogeneity is high (I 2 .90%),
In early COVID epicenters, CFR was 70% among patients aged more than 60 years of age. CFR increased exponentially with increasing age.
Specifically in the US across 21 studies (3,811 intubated patients), CFR was 47% (95% CI, 36–57%). Studies from New York reported a CFR of 54% (95% CI, 36–72%) whereas other regions in the United States reported a CFR of 41% (95% CI, 30–53%).
Definitive hospital CFR (aka for those with hospital discharge outcomes, 13,120 patients) was 56% (CI 47-65%).
Conclusion: Almost half of patients with COVID-19 receiving IMV died based on the reported CFR. The reported CFR was higher in older patients and in early pandemic epicenters, which may be influenced by limited ICU resources.
Limitations: Overall CFR of 45% still included patients in the hospital. Definitive hospital outcomes were only for 13,120 patients (36.6%). Significant variation in CFR exists between studies.
Lim ZJ, Subramaniam A, Ponnapa Reddy M, Blecher G, Kadam U, Afroz A, Billah B, Ashwin S, Kubicki M, Bilotta F, Curtis JR, Rubulotta F. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis. Am J Respir Crit Care Med. 2021 Jan 1;203(1):54-66.
Angriman F, Scales DC. Estimating the Case Fatality Risk of COVID-19 among Mechanically Ventilated Patients. Am J Respir Crit Care Med. 2021 Jan 1;203(1):3-4.
Download the UMEM Pearls App!
Subscribe to daily UMEM Pearls (FREE!) via:


text:
Be sure to give a metallic pan that not have not-perplex levels. My favorite material items are the Any kind of-Clad Chrome eight-Half inch Electrocute Pot as well as Virtually any Clad Steel one particular-1/2-Gal Gravy Cooking pot at Hood. A new warm surefire asian bags are any Lodge logic eight-Half inch Cooking'ersus Skillet and the A reputable company Square Barbecue grill Weed. Nonetheless, the degree of iron that's dispatched to the food is generally harmless if you haven't any issues with extra straightener. Below, you will find there's spot for dwelling heats up that will thoroughly ambiance for cooking, bake and possess new in the kitchen. Most people amount daily original recipe ingredients at strong creativities and tastes.
So, if you'lso are your vegetarian, you should think about for the utilizing a broiler pot which includes a important rubs surfaces your'lmost all in shape your whole greens. Total, many of us advocate you may pass on the particular broiler cooking pot trying no matter whether you must engage in totally-prepared foods. Computer chip doesn't stick to the gardening land, and it specified warms swiftly. If it is compatible is a dilemma by incorporating broiler griddles, but not the particular solution. It really works on significantly less Frigidaire stove tops however some other timely ovens. Nowhere full from the broiler weed area can be sight-attaining, and start a terrific way to stack shade towards the dining room.
All of us use'meters doing this package because the control lacks the no- https://mykitchenadvisor.com/grill-cleaners/ good drape or maybe safety terrain, and you simply will need potholders to get well-being. Alternative box teams such as GSI External Boogeyman Camper and commence GSI Outside the house Glacier Basecamper putting up about an typical boiling hour, longing a few a few minutes, t moments. Some sort of MSR Pottery spot is a bit faster resulting from stainless steel that has more significant conductivity along with a close-fitting package lid.
Nevertheless it gives you in order to very clear speedily at any dishwasher. The excellent benefits with the vitamin ensure that the symptoms does never react with food items which enables it to keep the foodstuff harmless and start tasty. This is a spot in which offer you a life association with no turmoil or deformations. It is made in several nick rank granite levels a remain it lets you do from strong problem with regard to long. It doesn't time totally and also quickly also beneath strenuous use.
A great Epa consultative monitor documented your PFOA is really a "possible carcinogen" on mankind. Here i will discuss my personal choices for any 3 greatest and initiate some worst types of asian kitchenware. Fantastic full price you need to good selection baking specifics. Also i appreciate bridges regarding recipke when We're some sort of food me! Bundt Meal Pansprovide a normal construction and begin kind if you'd like to a new meal.
My personal number of the superior ten very best earthenware asian any particular one may possibly Platform to acquire on 2021. You could start research online for many wonderful asian kitchenware, and you will have a look at the particular choices the actual you could have in the way far you need to pay money for the position. In existence the particular spot in order for you some thing larger intended for a new massage therapy, and you've got to understand that you can use this location so as to jumpstart a new lounge once you just lately moved with. Listed here kitchenware are made to provide you with a lot more information heat, and you'll start using these pans in most area for the reason that come to feel way too commercial.
A great one of those as a Nordic Squander professional-grade delivering that many of us indicated above, and you simply'lmost all never have to dread in a tight bed sheets or heating warping again. However, the pan is actually a exceptional development in the earthenware style. It'azines manufactured from another thing, and perhaps much more fun, when compared with grunter might be.
Taylor everyday life from the hills associated with Asheville, New york taking the girl hour or so reading her person focus on producers and going after your ex sons and initiate family pets and find out what they're screening to consume hence. You should definitely creating, Taylor can be obtained gardening, verifying, utilization a significant amount of cheese, and trying to fit more significant systems in her dining facility. A lot of bakers pay no attention to the best way main of any zap your weed might wear a final system. You could elevate your food preparation around entirely when you purchase the correct ones.
To start with, the created from large-quality precious metal, on what assures furthermore high temperature shipping. The preferably hinders the food on under preparing food or perhaps burners. Strength – This is usually a longer lasting grunter pan which has a greatest-reasonable not-baffle board land. And that means you might make equally as well as shed any tarts and commence cakes fully with this cooking pot. The modern several-And stone not for-perplex geography has tad petrol pockets regarding the worked products and start cookware, on which obstructions a cookies in in freefall or attaching. I'mirielle tests some sort of precious metal baking bedding but actively playing lambskin newspaper as well as arctic preparing carpets as a filling.
Thank you for your interest in working with Leslie Margarita. Please pop in your details below and we will contact you within 48 hours. We can't wait to hear from you!


text:
The Tsehai (ፀሐይ) Bowl Collection
The Tsehai (ፀሐይ) Bowls
Our large organic coconut wax vessel collection is appropriately named the Tsehai Bowl because "Tsehai" is the Ethiopian word for Sun. With over 15 wicks lighting this beautifully crafted bowl, it will bring light and warmth into your home.
Join Us
We will bring you designs and special products from around the world that will lift your spirits and bless you with comfort.
We're excited to share these treasures with you and invite you to join us on this inward journey… a Return to Home.
"Creating and sourcing beauty in different forms lifts my spirits. I share it with you in the hope that you, too, will be inspired. We are here to help you turn any space into a sacred space."
Stay connected. Join our digital community on Instagram.


text:
Editorial: Campaigns turning nasty
The two Democratic presidential candidates are threatening to - choose your political cliche - come out punching, take the gloves off, go negative, attack.
Hillary Rodham Clinton's campaign even has a term for the strategy - "the kitchen sink" - as in throwing everything, including the sink, at Barack Obama. It worked for her in Texas and Ohio.
She was hardly on the high road even before last week's game-saving victories, having earlier accused him of plagiarism, suggested he might be a Muslim and mentioned that one of his fundraisers was being tried on corruption charges.
Most recently, her campaign spokesman likened Obama to relentless Whitewater special prosecutor Ken Starr, perhaps not the best move since it gives the Obama camp an opportunity to reprise the Clintons' scandals of the 1990s.
It's not her first attack to cut more than one way. Her campaign ran the TV commercial asking who the viewers wanted to answer the phone in the White House when it rang at 3 a.m. The answer was clearly meant to be Hillary Clinton, but a common reaction was, "Now that you mention it, I think I'd like John McCain to take the call."
Obama, in turn, has stepped up his demand that she release her tax returns, her White House schedules as first lady and the fund-raising records of her husband's presidential library. This is a fair line of criticism; Clinton does not have a record of transparency and she and her husband worked harder at exploiting the campaign finance system than fixing it. It would be within bounds - if dangerous to his above-the-fray posture - to ask what role she played in the presidential pardons issued as the Clintons were leaving the White House.
Clinton claims that she's best equipped to withstand the Republican "attack machine" in the fall, and it's true that she's taken more punches than Rocky Balboa. Obama has yet to prove he can take a serious hit - or deliver one. Clinton's attacks leading up to Texas and Ohio seemed to throw him off stride, but now he is threatening to respond in kind.
The previews show he has yet to get the hang of it: "One of the things I hope people start asking is what exactly is this foreign-policy experience she's claiming. I know she talks about visiting 80 countries - was she negotiating treaties or agreements or was she handling crises during this period of time? My sense is the answer's no." As for Clinton being, as she says, "thoroughly vetted," "I intend to examine that argument." This is hardly red meat.
If the campaign turns nastier, that's no bad thing. It's a fair test of the candidates to see how they respond under pressure to attacks that are mean-spirited and unfair. Politics is unfair. The Republicans are unfair. The crazies in the Mideast are unfair. Life is unfair. Deal with it. We'll be watching.


text:
Finance Analyst, AWS AI and Machine Learning, AWS AI-ML Service Finance, AWS AI/ML
Company Details
Amazon.com Services LLC
- 3+ years of experience in finance or a related analytical field.
BA/BS in Finance, Accounting, Business, Economics, or a highly analytical field (e.g., Engineering, Math, and Computer Science) or equivalent and a minimum 3 years of experience in finance or a related analytical field, or an equivalent combination of education and experience.
Come and be part of the Amazon AWS Artificial Intelligence finance team! We are a cloud AWS service that helps customers run machine learning algorithms on various Big Data systems in a scalable and cost-effective manner. With Machine Learning, businesses now ask our machines to do more than repetitive, strictly-defined tasks. We are taking it one step further and have begun to ask them to not only learn on their own but to also interpret data and report to the customer before they even knew they needed it. It's a step in history for you to be a part of.
AWS Finance seeks a world class Finance Analyst to be a key member of its team. This position will serve as a key finance owner to support Computer Vision Services.
Key job responsibilities
- Taking the lead in financial planning; building complex financial models and analytical tools to measure overall financial performance
- Managing the AWS AI P&L and influencing business decisions that drive revenue and/or capital expenditures
- Developing short and long range financial/operational forecasts
- Developing and standardizing financial reports
- Providing financial recommendations on a variety of investments, deal negotiations, new product launches and regional expansions as well as the capital expenditure planning for a new product/region roll-out.
- Additional responsibilities include helping refine the capacity planning process and modeling improvements to help drive positive Free Cash Flow.
This role requires a self-starter with a strong financial modeling background, problem solving skills, a keen attention to detail, ability to work in a fast-paced environment with ambiguous situations, and solid skills in project management. This role has regular interaction with various business units across Amazon and requires strong people skills.
Advanced knowledge of Excel/ financial modeling Advanced financial modeling skills, including knowledge of SQL Strong interpersonal skills — including written and oral communication skills An ability to meet tight deadlines and prioritize workload An ability to develop new ideas and creative solutions An ability to work independently and self-motivate in a fast-paced and rapidly-changing environment Knowledge of cloud computing industry Experience in a technology company or high-tech environment Experience with TM1/Cognos or similar tools Amazon is committed to a diverse and inclusive workplace. Amazon is an equal opportunity employer and does not discriminate on the basis of race, national origin, gender, gender identity, sexual orientation, protected veteran status, disability, age, or other legally protected status. For individuals with disabilities who would like to request an accommodation, please visit https://www.amazon.jobs/en/disability/us.
To apply for this job please visit www.indeed.com.


text:
About Course
API 510 Training Certification Courses Paris FranceIn today's API 510 Training Certification Courses Paris France worldwide service economic climate, it is important for ventures to finish API Inspections efficiently across different sector markets. The API a worldwide controling body that recommends API 510 best practices through A Guide to the API Body of Knowledge. The variations of the API guide will certainly be changed consistently, remembering the trends and modifications in the field. Look into the dates listed below for the API 510 certification program of your option to enrol now. API 510 Training Certification Courses Paris France Today anything and also everything is a API Inspection. In this API Inspection-based organization landscape, it is vital for individuals and also enterprises to accept API Individual Accreditation Programs structures and also ideal techniques to supply maximum worth. As ventures are shedding more than 100 million bucks for each billion spent on API Inspections, it needs a significant modification in the way API Examinations are managed on a day-to-day basis. API 510 Training Certification Courses Paris France the best component concerning API 510 certification courses is that none of the training adheres to a certain structure.
API 510 Training Certification Courses Paris FrancePrograms are all based upon the extensive experience of API Examination professionals internationally coming from numerous sector markets such as construction, gas and oil, energy, retail, manufacturing and a lot more. With inputs from such a broad array of fields, it makes the API 510 accreditation training courses genuinely international in nature, and both business and specialists have prestige for API 510 accredited experts in the marketplace. API 510 Training Certification Courses Paris France. There are many API Individual Accreditation Programs frameworks and preferred qualifications, however API 510 certification training is the gold standard in the industry, and also the API 510 chapters held across the globe assist the Overview to stay pertinent by making version adjustments at normal intervals.
Several of the preferred API 510 Certification training courses are:1- API 510 Accreditation Training: Anyone who is interested in API Individual Accreditation Programs occupation recognizes that API Person Certification Programs Professional (API 510) is just one of the most popular qualifications from both companies and also experts alike. API 510 Training Certification Courses Paris France There is no question regarding the popularity of the API 510 certification as there are nearly greater than 1 million+ API 510 accredited specialists globally. This API 510 Exam Preparation is a 15-day instructor-led interactive training that can be provided both as a classroom and also live on-line training. Participants who attend this API 510 program will receive a course completion certificate and 35 API 510 PDUs to obtain their API 510 certification exam.
API 510 Training Certification Courses Paris France Discovering GoalsIn this program, you will certainly establish and take care of a group to plan, exec, and complete a task that is aligned to business environment. You will: 1. Create a high-performance job group 2. Plan and manage the project 3. Perform and also review the project tasks 4. Aid team focus on track 5. Maintain business atmosphere in mind
API 510 Training Certification Courses Paris France Teaching and Knowing ApproachA mix of talks, conversations, workouts, and also participating learning will certainly be used. Energetic understanding will certainly focus on reviewed based on student task circumstances connected to the application of qualitative and also quantitative techniques that will help with choice making in task monitoring issues in both the regional as well as international contexts and examined through a common structured response question. API 510 Training Certification Courses Paris France covers Finally, a cumulative thorough assessment at the end of the training course will certainly evaluate understanding of the core concepts.
Who can take up API 510 Accreditation Training?
Job duties that can gain from API 510 certification training programs are:API Assessment Managers. Business Analysts. API Examination Team Leads. API Assessment Consultants. API Inspection Enrollers. Item Proprietors. QC Managers. QA Managers. API Inspection Coordinators. API Examination Analysts. Associate API Inspection Managers. API Examination Group Members. Aspiring API Assessment Managers. Professionals that intend to get an all natural understanding of API Person Certification Programs principles. API 510 Training Certification Courses Paris France Any person who is looking to remove their respective API 510 accreditation exams. Factors to choose API 510 Certification Courses from API Examination Solutions. A wide profile of API 510 Qualification courses for specialists throughout numerous degrees and also sector fields. API 510 Training Certification Courses Paris France Obtain learnt a few of the most in-demand API Individual Qualification Programs and Agile accreditation programs from API 510. Expert API Individual Certification Programs as well as API 510 trainers with real-life experience to make you understand how to incorporate API Individual Certification Programs best techniques for your API Assessments to complete them efficiently. API 510 accreditation course material prepared by Subject Professionals with appropriate study and also seminar to obtain a detailed understanding of the PMBOK Guide as well as various other manuals from API 510. Obtain API 510 Qualification training from a API 510 Education Carrier worldwide. API 510 Training Certification Courses Paris France Functioning trainees and also professionals to obtain two flexible time slots in 8 hours/ day and also 4 hrs/ day alternatives to occupy their API 510 qualification training courses. Enterprises as well as teams to obtain customized API 510 training and also routine that fulfill their company/ team needs. Get 1-to-1 training as well as Fly-me-a-trainer alternative to obtain specialized focus for your particular discovering demands. Be part of 'Guaranteed to Run' API 510 Qualification training sessions with 'Examination Pass Warranty'.
Just how to Request the Test?
API 510 Training Certification Courses Paris France Applicants will need to finish the following steps to apply for the API Evaluation 510 Examination:Register with API as well as log into your account after enrollment. Get API Subscription as well as finish the on-line application. Submit the application online. Upon acceptance, you Will need to arrange your examination.
API 510 Training Certification Courses Paris France Examination:The examination is a multiple-choice computer-based examination. The examination includes 180 inquiries, as well as it takes around 7 hrs to complete.
Keep Your API Examination 510 QualificationAPI Examination 510 certification lasts for 3 years from the date you got your original certification. API Inspection 510 certification owners should meet all continuing education needs in order to retain certification. API Evaluation 510 certification lasts for 3 years from the date you acquired your original accreditation. API Assessment 510 accreditation owners have to fulfill all continuing education needs in order to retain certification.
API 510 Training Certification Courses Paris France Contacts
API 510 Training Certification Courses Paris France Speak to instructor
API 510 Training Certification Courses Paris France LinksContact Us For Additional Information
What Will You Learn?


text:
Dear Residents and Families/Representatives,
Currently there is an increase in COVID-19 cases across Sydney which creates a higher risk to our residents and workforce. Due to this increased risk there are measures in place, as a precaution, to provide COVID safe connections between residents and their family or friends.
Requirements when visiting a resident
Visitors must not enter an aged care facility at all if they:
Visitor requirements:
If you would like to visit a resident for compassionate reasons, please feel free to reach out to the Management team of the home where your loved one resides so we can ensure a compassionate and dignified journey no matter what your vaccination status is. We are happy to speak with you about the choices available.
If you have any queries or needs for an outings please reach out to our home so they can conduct an initial risk assess in consultation with the resident and/or their representative. Subsequently you will be asked to complete an outing form and a declaration form.
Residents may leave the facility and attend family gatherings or for other reasons but must abide by the current Public Health (COVID-19 General) Order (No 2) 2021.
Residents should not leave the facility if they have COVID-19 symptoms until they have had a RAT or PCR test and have received a negative result. Please be reminded that a resident should get a booster dose as soon as they are eligible for one.
Do you have questions?
If you have any queries or concerns, please reach out to your facility General Manager or Administrators who will be happy to speak with you.
Thank you for your support and cooperation while we care for your loved ones.
Yours sincerely,
Spiro Stavis
Chief Executive Officer
New visitation guidelines in force from 15 April and requirements for visitors to have a current flu vaccination.
Department of Health | Fact Sheet on visiting residential facilities
An information sheet from the Dept of Health for families and residents on restricted visits to residential aged care facilities on how to prevent the spread of coronavirus (COVID-19)....
Non-essential visitor restrictions at Randwick and Kensington Homes
In line with advice from Australian government health agencies regarding visiting restrictions within our Randwick and Kensington Homes due to COVID-19, the following requirements are in place as of...


text:
Updated: Aug. 10, 2022 at 8:18 AM PDT|
Local farmers are asking you to share the road this summer.
Updated: Jul. 13, 2022 at 8:00 AM PDT|
In this Behind the Wheel, Tony Martinez shows you how any driver can be a better driver with a few simple tips.
Updated: Jul. 6, 2022 at 8:03 AM PDT|
What's the most dangerous thing to consumer while driving? Hot coffee! That's just one of the questions Tony asks Andy in this car quiz.
Updated: Jun. 29, 2022 at 8:17 AM PDT|
A Portland man has been collecting license plates all of his life. He shows off his collection in this Behind the Wheel.
Updated: Jun. 22, 2022 at 8:00 AM PDT|
Races at Portland International Raceway would not be possible without volunteers from the Sports Car Club of America.


text:
BTS's Jimin is not what you'd call "subtle". His reactions and emotions are always over the top, and we love him for it! Here are 10+ of Jimin's most dramatic moments yet.
1. When he cried, "Oh, my eyes! Oh, my eyes!" in an interview
2. Jungkook accidentally bumped Jimin's belly so, naturally, Jimin keeled over
3. That time he threw his gloves away…
…and a little girl walked all over on them
4. When cute clothes made him gasp
5. When Suga ignored his "peak" drama
the way yoongi completely ignores jimin's dramatic monologue and just goes "my nostrils are so cold. they smell like blood" is so FUNNY 😭 pic.twitter.com/Jjb7WgARff
— zai⁷ 🍒 (10.1K) (@awjiminie) December 5, 2019
6. Screaming in a gallery, because why not?
7. This exaggerated expression
8. This "I'm so done with you" sigh
9. When he "almost died" on a ride
here's a loop of jimin with messy hair being dramatic & screaming "I ALMOST DIED" pic.twitter.com/h1nRnNz95r
— pat⁷ (@koostrology) May 1, 2018
10. When he actually "died" in the Mafia game
11. Another GASP, but in all caps
12. When he acted like this while getting his arm measured
13. This over the top exit
See more dramatic Jimin moments here:
jimin's extra funny when he's being dramatic and that's a fact pic.twitter.com/t8coeybtkN
— ⁷ᴊ ᴍ ᴛ ₁₃ (@jiminticaI) March 23, 2020
Here Are 20 Motivational Quotes From The BTS Members In A Brand New Voice Letter For ARMY
BTS's Jin And LINE FRIENDS' RJ Makes An Unexpected Appearance On "MasterChef"
Why ARMYs Are Editing FINNEAS Out Of BTS's J-Hope And RM's Photo With Him And Billie Eilish
BTS's Jungkook Talks About Just How Involved He Was In The Production Of His Photo-Folio


text:
Can bed bugs get under your clothes? Bed bugs will wander around your body until they find skin… Making it more likely that they can get underneath your clothes. Other insects such as fleas, are much more likely to go after your legs or feet. Bed bugs, more often than not, will stay around your upper body when looking to feed.
Do adult bed bugs feed every night? They don't feed every night after gorging themselves. Instead, they take between five and 10 days to digest your blood, then they mate and lay eggs before heading back to your bed for another feeding.
What can I put on my dog for bed bugs? While there currently aren't products that treat bed bugs on your pet, you can use soothing or anti-itch shampoo, relief sprays and antihistamines to help your pet feel more comfortable. Products that treat your carpet, upholstery and home can help remove bed bugs from your home.
Do Snipers kill bedbugs? If evidence of bed bugs are found, Sniper works with you to remove visible bed bugs and treat the areas to eliminate any hidden bed bugs and their eggs. Sniper backs the results for 30 days or re-treatment is performed for no additional cost.
Can Bed Bugs Live In Your Clothes
Can bed bugs get under your clothes? – Similar Questions
How to rid bed bugs on body?
Pyrethrins and pyrethroids are the most common chemicals used to kill bedbugs. However, some bedbugs have become resistant to them. Pyrroles, like chlorfenapyr, kill bedbugs by disrupting their cells. Neonicotinoids are versions of nicotine.
What does bed bug bites look like on dogs?
What do Bed Bug Bites Look Like on Dogs? Bed bugs bites on dogs are often small red welts or itchy lesions, which sometimes get mistaken for flea or mosquito bites. They'll sometimes be in a line or cluster. Bed bugs on dogs seek out heat so you will likely find bed bug bites on dogs' bellies or limbs.
Can bed bug live in dust?
"House dust mites live where dust accumulates, and bed bugs are found where people are found," DeVries says. Another distinction: Dust mites don't bite. Instead, they feed on your dead skin cell flakes that you shed in abundance every day.
How often do bed bugs have to feed?
Though their feeding schedule is unpredictable, bed bugs will feed every 5 to 10 days or once a week when food is available. Though it is common that bed bugs feed at night, the frequency may depend upon: Population size. Host availability.
Do bed bugs bite your fingers?
Bed bugs usually like to bite those areas of skin that are exposed during sleep, typically the shoulders, arms, legs, back and face. Bed bug bites also tend to be in a row.
Can bed bugs harm dogs?
A: Bed bugs don't live on pets or spend as much time on your pet as the more common pests (such as fleas, ticks, lice and mites), but they can bite your pets.
Do bed bug eggs stick to pets?
However, bed bugs are more likely to hitchhike on family pets for transportation to humans. Bed bugs don't lay eggs on their host, so rest assured that your pet is safe against nests in their fur. If you're worried about bed bugs in your home, on your pet or elsewhere, give Ehrlich a call at 888-984-0186.
How to avoid bed bugs bites?
Share on Pinterest Washing bedding at high temperatures and checking for signs of bed bugs in hotel rooms can help prevent bed bug bites.
How to make bed bug killer spray?
Two simple ingredients and bedbugs be gone! What is this? Mix equal parts of water and rubbing alcohol and spray all the areas the nasty little critters are hiding and have made their new home. This will stop them from spreading and laying eggs.
Are bed bug bites bumps?
Bed bug bites cause itchy red bumps. They are usually less than ½ inch (12 mm) in size. Some are larger (like a hive). These are normal reactions to a bed bug.
How to check luggage for bed bugs?
Or make use of your luggage rack to keep suitcases off the floor. Pull back blankets and linens, and examine the bed frame and headboard for reddish-brown and dark marks. You may actually find bugs and their young offspring, or nymphs, as well.
Where does bed bug protector go?
A bed bug mattress protector is a large, removable sheet of fabric that fits tightly around your mattress, fully encasing the mattress. Each protector includes a zipper that locks particles — and pests — inside. Once locked inside, bed bugs have no way of escaping from the encasement to reach their blood supply host.
What bites behind the knee?
Chiggers like to bite in folds of skin as well as places where clothing fits tightly. Most chigger bites occur around the ankles, waist, armpits, crotch, or behind the knees. You won't feel it when the chigger latches on, and you probably won't feel a thing when it bites.
How do I keep bed bugs off my baby?
Wash the child's skin at the sites of the suspected bites with soap and water. Apply an over-the-counter, anti-itch cream or oral medication to control itching. Limit excessive bedding and plush toys in and around a child's bed. If bedbugs or bites are found, an exterminator is needed to eliminate the pests.
Can bug bites be itchy for weeks?
An itchy papule or wheal may develop and persist for several days. Eventually, most people become immune and insensitive to the saliva after receiving a number of bites. Allergic reactions to insect bites do not normally last more than a few hours, but sometimes they can linger for months.
Can you smash a bed bug with your hand?
Can You Squish a Bed Bug? Yes, you can squish bed bugs so easily. If the bed bug has not had a blood meal, it can easily slip past your fingers and you may need to apply extra force or use a rough object. The most important thing is to avoid staining your carpet or bedding when doing so.
Can you catch bedbugs from a patient?
Bedbugs are not spread directly from person to person. As stated above, they are spread by travelers and/or people who come in contact with bedding, clothing, or furniture that contains bedbugs.
Are bed bug bites always flat?
While not always the case, bed bug bites are often grouped together in a small area and at times may occur in a line or a zigzag pattern. Bites normally look like small, flat or raised areas that may become inflamed, itchy, red or blistered.
What problems do bed bugs cause?
Bed bug bites can cause a number of problems ranging from allergies, itching, swelling, and insomnia to anaphylactic shock. Bed bugs bite at night while you are sleeping and your defense is weak. You can be bitten as many as 500 times in a single night in the event of a serious infestation.
Do bed bug bites feel like bumps?
Bed bug bites can cause itchiness. Initially, a victim may detect a slight burning sensation. The burning area then develops red bumps, known as papules or wheals (rash). In extreme cases, bites may swell dramatically or turn into blister-like skin inflammations.
Does cleanliness affect bed bugs?
The thought that bed bugs are the result of poor sanitation and/or poverty is a big misconception. Bed bugs do not discriminate based on one's social status or the cleanliness of their home. The fact is that cleanliness has nothing to do with getting bed bugs.


text:
The Texans played poorly Sunday and were teetering on the verge of getting humiliated by the NFL's most dynastic franchise on their own field. They wound up losing only 27-20.
Because the Patriots are the Patriots and Tom Brady is Tom Brady, I'm going with the glass being half full, rather than half-empty. Not surprisingly, Bill O'Brien is similarly inclined.


text:
WESTLOCK – During the Jan. 19 Westlock Regional Waste Management Commission meeting held via Zoom, the commission was approached by AltRoot Compost which requested and received approval for an expansion of its services at the Westlock Regional Landfill.
AltRoot is a compost organization that takes organic waste and breaks it down into a natural, organic compost that is provided to producers to use in their fields. The program entered a partnership with the commission to help keep organic waste out of the landfill, saving much-needed space while providing local producers with another option for fertilizer.
Currently, the operation processes 20,000 tons of organic waste each year but hope to go beyond that. In order to do so they needed permission from the commission to begin expanding their services, which will require about three and a half acres of space.
Out of the 20,000 tons, 10,000 tons of fertilizer is produced with around five per cent of the waste being contaminated and unable to be processed.
"Over the past year we've been told by so many people that this capacity restraint is getting worse and worse," said AltRoot representative Brian Wonnacott. "There is an opportunity to do a service to our province and region to do this duty."
In a PowerPoint presentation, Wonnacott showed the commission how their composting process works. The process begins with aerators laid underneath organic waste, the waste is then covered with fully composted fertilizer to help with the decomposition process by trapping heat and preventing any smell. On average, the internal temperature of the compost piles remains around –30 C even in the middle of winter.
"We have put in processes to manage and process this specific waste in a way that it makes it easy and economical to process," Wonnacott said. "We've designed it to be simple and efficient."
By expanding operations, Wonnacott said AltRoot can provide more compost for producers while bringing in more vehicles to drop off waste. The site sees between three and five semi-trucks full of waste a day, netting the landfill $10 for each truck with weighing costs.
Landfill to reopen five sealed cells
A motion was passed to take out a $175,000 loan over seven years to begin work on reopening five cells in the landfill.
Cells are pits dug and filled with waste then covered once full, however commission manager Tom Moore said that by reopening five pits they can add roughly five metres of waste to each cell. The current pit only has a year or two left until it is filled, and to dig a new one would cost around $350,000.
By doing a height adjustment to five sealed cells, an additional six to seven years will be added to the lifespan of the landfill before more cells are needed to be made. Over the next decade-and-a-half Moore anticipates saving around $1.5 million with this work.
"To me financially it's a no brainer," said Moore.
The cost of opening the cells will total around $60,000 to $70,000 with the remaining money going towards a 600 foot long 25-foot-tall fence on the southern side of the landfill and portable fences to keep waste from being blown from the site and into surrounding fields.


text:
Monster Hunter Rise: Sunbreak has been out for roughly a week. While longtime players have no doubt reached the endgame by now, new players may still be working their way through the story. But how exactly do you start the Sunbreak expansion?
First off, complete the 7-star Urgent Quest "Serpent Goddess of Thunder." This pits you against the final boss of the base game. If you're starting from the beginning, it's about 15 to 20 hours to reach this point. Even more content becomes available after slaying the final boss like Apex Monsters, Event Quests, Elder Dragons, Decoration crafting, and annoying Talisman RNG. While these will be essential in creating a strong build, you can worry about them later.
After finishing the Urgent Quest and watching the "ending," go to the entrance of Kamura Village. Rondine, the trader, will be present and ask to speak to you. The 7-star Quest "Uninvited Guest" will then become available. It involves battling a brand new monster in the Shrine Ruins.
Though not as tough as the base game's final boss, be careful – they can dish out some real punishment. Don't worry about grinding out High Rank gear – be patient, use Wyvern Riding and it should fall.
After the hunt, it's off to Elgado where Master Rank becomes available. You'll get a few 1-star Master Rank Quests but we suggest veering off the main path and slaying some Velociprey in the new Jungle region. Use their materials and craft your first Master Rank armor set.
Along with higher defense than your High Rank sets, it also has skills like Attack Boost x5, Windproof x3, and Stun Resistance x3. It also provides Decoration Slots for two Level 4, two Level 3, three Level 2 and one Level 1 Decoration. In terms of value and ease of obtaining, the Velociprey Set is your best bet. Check out Arekkz Gaming's video below for more details.
Monster Hunter Rise: Sunbreak is available for Nintendo Switch and PC. Stay tuned for more details and guides on it in the coming days.


text:
Accounting Services For Dentists
Why a dentist should outsource accounting work?
A dentist always cares for his or her patients by providing oral health facilities to smile at them. Although, for running your small or large dental practices successfully, you also need to maintain an accurate financial record of your transaction by following proper tax compliance. You should look here to get superior accounting services, especially if you are a dentist.
Are you facing problems in maintaining books of accounts? Do you need any tax or financial guidance for bookkeeping? Our accounting professionals having many years of dental accounting experience will help you to provide the best accounting facility to grow your dental business. This not only will reduce your administrative workload but also you will get help in financial planning and tracking.
Our aim to provide comprehensive accounting, payroll, and tax management services at affordable prices. Our dental accountants are experts in the reduction of taxes and maintaining and preparation of financial data. We have experts who will ensure your minimum tax liabilities and the healthy financial position of your dental organization. It does not matter which accounting software is because our team is dedicated to working with software like QuickBooks, SAP, Simply Accounting, Marg, Tally, Busy, and a good deal of other software.
A brief list of Dental Accounting services
Setting up accounting software
Maintaining books of account
Complete Reconciliation for bank and credit card
Payroll management and processing
Preparing budgets and financial projection
Preparing financial statements
Tax calculation and preparation
Maintaining accounting payable and receivables
Analyzing cash flow and monitoring as well
Also, preparing personal financial statements
The list of the accounting service process
Accurate and up-to-date accounting
They always take care of client's requirements and to assure the working process here is the succinct description
First, we receive data or files in the form of scanned downloadable formats and review it and if something is missing out the ask for the same, to ensure accurate work this is essential.
Performing next steps like passing entries of cash, banks, credit transactions, reconciling the bank and credit card account. Payroll maintaining and processing, reviewing financial data to measure quality and accuracy.
Sending all required financial data that is ready to decide on and also provides suggestions and feedback for better financial flow.
Responding to clients' responses and doubts, to solve their queries.
The best part about our expert team is their adaptability because they understand all the requisites immediately and start working to make their client happy and relaxed. So, after submitting your work you can stay relaxed and focus on vital administrative tasks that it to facilitate your patients without having any burden.
What are the advantages of outsourcing your medical practice accounting?
Skilled accountants do the work for you.
Our skilled accountant having many years of experience does the entire work for you. They are professionally trained experts who systematically maintaining records as per your industry requirements. it is reliable as well because they can deliver you high-quality work as they are skilled professionals.
It is also affordable when it comes to pricing
The greatest advantage of outsourcing your medical accounting liability is that it is much cheaper because when you will hire an accountant for yourself as a full time then you have to spend a lot of money. Which can be costly for small and medium dental clinics. By outsourcing this you can save money and also reduce administrative work.
Work completed and delivered on time
As you will outsource your financial work to skilled experts, then they will work on their own with crucial tactics to work fast and effectively. So, you will get the work done on time. Also, they are trained in competitive environments and know how to settle with workload pressure. So, they can do better without making any mistakes.
Error Free and accurate work benefit
Dental accounting processing needs to have well-maintained books only then you can follow the legal compliances and also this is challenging to complete the whole work within the given time. If you hire an employee for this, you will be responsible for any error and also he may make mistakes if he does know medical accounting. So, outsourcing your work to a well-structured company can help you to get error-free work by following legal policies. Also, your account will be up to date with the latest rules and regulations.
Trust is another key to outsource financial requisites
When you outsource your dental accounting, your accounting data is monitored and checked by a dedicated team who is an expert in a variety of required skills like bookkeeping, payroll, budgeting, taxation, etc. There is also a great possibility that you will not have to worry about leaves or staff change. They handle all this so you just need to wait for your final data before and after-tax compliance.
Data Security is also considered the topmost priority
Outsourcing firms and companies also take care of your data and they never allow anyone to misuse it as there water only professionals who are dealing with the same kind of scenario for a long time. we also followed internal and external security measures for data protection.
Saves time and you can focus on your patients
As a dentist, you need to see a lot of patients in a single day. So you cannot think of maintaining books of account to keep track of financial flow in your company. So, when you outsource your medical accounting then others do the work for you. Which is extremely essential for you to deal with your work and keep growing your dental business with time.
So, in the end, with outsourcing, you can expect 100% accuracy for correctly maintaining your books of account and following legal requirements. The team is available for you 20*7 for providing the best dental accounting services with reasonable pricing. If you own a dental clinic and can not afford an accountant then outsource your accounting work to get surety for your best practice