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Boris Johnson has thanked voters in the north of England for "breaking the voting habits of generations" to back the Conservatives.
Speaking in Tony Blair's old seat of Sedgefield, the PM said he knew "how difficult" that decision can be.
Mr Johnson won a Commons majority of 80, his party's biggest election win for 30 years, by sweeping aside Labour in its traditional heartlands.
In contrast, Labour suffered its worst election result since the 1930s.
Activists chanted "Boris" as Mr Johnson arrived in the County Durham constituency, which returned a Conservative MP on Thursday for the first time in 84 years.
The prime minister said he wanted to thank voters in the "incredible" constituencies in north-east England for placing their trust in the Conservatives.
They had "changed the political landscape" and "changed the Conservative Party for the better", he said.
"Everything that we do, everything that I do as your prime minister, will be devoted to repaying that trust," Mr Johnson added.
"We are the servants now and our job is to serve the people of this country and deliver on our priorities. And our priorities and their priorities are the same."
Leader Jeremy Corbyn said he had done "everything I could" to get Labour into power but expected to stand down "early next year", after a successor has been chosen by the party.
He said the general election had been "taken over by Brexit", the issue on which Mr Johnson campaigned most vociferously – but other figures in the party have disagreed over the reason.
Shadow chancellor John McDonnell promised to "learn lessons and we'll listen to people" during the debate over the future of the party and its next leader.
"My fear is that we're in for the long haul now, possibly five years," he added.
Labour's Helen Goodman, who lost the seat of Bishop Auckland to the Conservatives, told BBC Radio 4's Today programme that "the biggest factor" in Labour's defeat "was obviously the unpopularity of Jeremy Corbyn as the leader".
However, the Labour MP for York Central, Rachel Maskell, said: "We've all got to take responsibility… I don't think apportioning blame to a complex situation in a simplistic way is really the way to approach this."
Mr Johnson is expected to announce a minor government re-shuffle as early as Monday.
Asked whether his promise to be a one nation government meant bringing back Tory politicians like Penny Mordaunt and Jeremy Hunt – who left cabinet in July after Mr Johnson took over – the PM said he was "not going to speculate about personalities".
MPs will then return to Westminster on Tuesday and begin the process of swearing in, before the Queen formally opens Parliament on Thursday with "reduced ceremonial elements".
The prime minister has also vowed to reintroduce his Withdrawal Agreement Bill to Parliament before Christmas, which could happen by the end of next week.
It would see MPs begin the process of considering legislation that would pave the way for the UK to leave the EU on 31 January. Talks about a future trade and security relationship will begin almost immediately.
Former Conservative Deputy Prime Minister Lord Heseltine, who opposes Brexit and backed the Liberal Democrats in the election, told Today: "We've lost. Brexit is going to happen and we have to live with it."
Asked whether he would support any future campaign to rejoin the EU, he said it would be "20 years or something before the issue is once again raised".
Protests took place at Westminster on Friday following Mr Johnson's election victory.
Demonstrators in Westminster carried signs that read "Defy Tory Rule" and "No to Boris Johnson".
The Metropolitan Police said two people had been arrested in relation to the protests – one person on suspicion of assaulting a police officer and another for suspected affray.
Following the Conservatives' election win, Mr Johnson spoke to SNP leader Nicola Sturgeon on Friday evening and reiterated his opposition to a second independence referendum in Scotland.
The conversation came after the first minister said the PM had "no right" to stand in the way of a second vote following her party's "overwhelming" election performance. The SNP won 48 of Scotland's 59 seats.
Speaking on Radio 4's Any Questions on Friday, cabinet minister Thérèse Coffey insisted there would be no referendum on Scottish independence during the Conservatives' five-year term.
After speaking to Ms Sturgeon, the PM also took phone calls from German Chancellor Angela Merkel and Irish Prime Minister Leo Varadkar to discuss the next steps on Brexit.
The Conservatives won a total of 365 seats in the election, while Labour finished on 203, the SNP on 48, Liberal Democrats on 11 and the DUP on eight.
Sinn Fein has seven MPs, Plaid Cymru four and Northern Ireland's SDLP two. The Green Party and NI's Alliance Party have one each.
The Brexit Party – which triumphed in the summer's European Parliament elections – failed to win any Westminster seats.
The Conservatives swept aside Labour in its traditional heartlands in the Midlands and the north of England and picked up seats across Wales, while holding off the Lib Dem challenge in many seats in the south of England.
Voter turnout overall, on a cold and damp polling day, was 67.3%, which is down by 1.5% on the 2017 total.
Meanwhile, the Liberal Democrats are looking for a new leader after Jo Swinson lost her Dunbartonshire East seat to the SNP by 149 votes.
While she admitted her "unapologetic" pro-Remain strategy had not worked, she said she did not regret standing up for her "liberal values" and urged the party to "regroup and refresh" itself in the face of a "nationalist surge" in British politics.
Sir Ed Davey and Baroness Sal Brinton will be acting co-leaders for the party now that Ms Swinson is no longer an MP.
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Let Us Know You're Here -- Please Fill Out a Connection Card
Be Weak. Be Strong. Belong.
Sunday Message Series
September 13 - November 22
Online worship beginning at 9:00 a.m.
- Scroll down to view or find us on Facebook
- Order of Service available the Thursday prior: faithwestwood.com/service
In-Person worship -- 9:00 a.m. at FaithWestwood
Series Description:
When we belong to Jesus, we learn to embrace paradox. We give in order to receive. We humble ourselves to be exalted. We conquer life's challenges through surrender. And this one: we accept our weakness in order to receive God's strength. This paradox is a theme in one of the most heart-felt books of the Bible -- Paul's Second Letter to the Corinthians.
This fall Pastor Steve Todd will give a series of Sunday messages based on 2nd Corinthians. Plus, we'll have a copy for you of N.T. Wright's devotional to read at home, Paul for Everyone: 2 Corinthians.
As we prepare to engage in this series, now would be a perfect time to join a FaithGroup – or help launch a new one. Each week these small groups discuss Sunday's message and how it relates to their everyday lives. If you're interested in joining a FaithGroup or starting a new one, contact Director of Adult + Family Ministry Holly Timberlake at email@example.com.
September 13
Comfort: Copy and Share
2 Corinthians 1:3-11
When we're hungry, we often turn to our favorite comfort foods. When we're ready to relax, we enjoy the cozy feel of comfortable clothes. And when we're hurting, we welcome a comforting hug. In our suffering God is ready to comfort us -- it's a gift we then pass on to others. It starts a chain reaction of comfort during life's most stressful times.
This week read 2 Corinthians 1:1-14.
September 20
A Dose of Healthy Sorrow
2 Corinthians 2:5-11; 7:5-11
How do you deal with uncomfortable feedback? Maybe you avoid it. Perhaps you deny its usefulness or shrug it off completely. But what if you choose to learn and grow from it? Facing difficult news about ourselves and resolving to change is what the Bible calls "godly sorrow."
This week read 2 Corinthians 1:15 – 2:13; 6:14 – 7:16.
September 27
What Does This Church 'Smell' Like?
2 Corinthians 2:14-17; 3:1-6
There's nothing like the smell test -- that informal way we use our own perceptions to determine whether something is reliable or trustworthy. When you hang out someplace, you can quickly tell if it's the real thing or not. What about our church family? Is it real? Is it healthy? Is it honest? Is it true to the gospel? What does this church 'smell' like to you?
This week read 2 Corinthians 2:14 – 3:11.
October 4
The Gospel: For Us, Not About Us
2 Corinthians 4:1-6
The next time you visit a new church, ask yourself some questions as you walk away. Did you come away more impressed, more in love, with Christ – or with the technology? Did the message point to the day's speaker or to the Savior? Did the people expect their needs to be catered to -- or did they lean into their Christian role as servants of the community? It's all about how we understand the gospel.
This week read 2 Corinthians 3:12 – 4:6.
October 11
Treasure in Clay Pots
2 Corinthians 4:7-12
It's totally human to try to impress others. We want to appear successful and beautiful and talented so we'll get noticed. We want to be admired and respected. But there's something refreshing – and freeing -- about being comfortable with our ordinary selves. In Christ, we can be at peace, because we're all carrying a hidden treasure.
This week read 2 Corinthians 4:7 – 5:10.
October 18
Ambassadors for the King
2 Corinthians 5:16-21; 6:1-2
Who's been your biggest influence in coming to faith? Think of someone who helped you know Jesus and learn what it means to belong to him. That person was an ambassador for Christ – they represented Jesus to you. How did you respond? How will you respond? Thank God for those ambassadors of Christ.
This week read 2 Corinthians 5:11 – 6:13.
More to come through Nov. 22...

subset: commoncrawl


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Her So tell me, what exactly does a gorgeous guy like me gotta do to acquire a kind hearted girl to accompany him into some chain bar /restaurant that is middling? Complement myself? Check. Inform her we're likely to drink at a spot with a bunch of crazy crap on the walls and everything that is mediocre? Check.
Speaking If you believe you are introverted, shy, or perhaps booked, then it's a good idea. Ifyou're certain thatyou're quite talkative please begin listening more and talking less. It's essential to strike a balance between being a good listener and a speaker. Find the middle ground and stick with it. Knowing when to talk and when to hold your tongue will improve your situation and tiwlight sex dating gaems South Miami Heights FL probably do you a lot of good in South Miami Heights FL local sluts in 34667. This ability shows. By doing this, you are showing that you are assertive and can manage yourself.
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Imagine if you are tired and drained as a result of travel with your flame and you have no communication whatsoever besides telepathy and you don't wish to go through it? Well, I understand that most people would advise you to keep strong and do your inner work which I agree with as really effective guidance but I also feel that being practical, and taking action on your trip improves the quality and nature of your Double Flame procedure.
You see we lived in a world of karma. We lived in a gta 5 prostitutes South Miami Heights FL where what we did has become who we are. We lived in a universe where haunted usand it turned into our mission statement. This ancestral local sluts down to fuck South Miami Heights Florida changes to a dharma world, where we're currently doing support to our loved ones, ourselves, friends, community, nation and the world around us. From the floor up, we're changing everything we view ourselves. First step reconnect to self, and our energy. The I am changed by us and live by the Golden Rule. If doubt creeps in, we learn to communicate curiosities and our feelings in our romantic relationships.
Activation mantras Let's talk which you can start to recite which will help you to help yourself activate the mind. Why trigger the mind? It's because your mind is where the magic is local sluts reddit South Miami Heights to discover your soul mate, and to arouse you. That word sparked, does this scare you? Aroused. And I am not talking I am talking about a brand new level of spirituality that is linked to that equilibrium of the Masculine and Feminine, sensitivity, and intimacy. For better or for worse, we could say male and female. We have that indoors.
Meanwhile- - and here's the part that is ironic- - the people who are more worried about giving are more financially successful than the executives hoping to deceive and steal their way. Stealers and the cheaters suffer inevitable defeat as they construct connections that are horrible and thrive in cultures of reciprocal consumption until they start to eat each other like rats. The givers, however, experience success as they've built respect and true allegiances that will last through any emergency.
She's told: " Do not dress for other women. Wear clothing to draw men. " You need to: Agree and use this as intel. " High- fashion" girls( those are the ones wearing clothing that confuse you since they're not pretty- - a bit odd! ) Are there to be seen by fashionistas, to not be picked up by men. If you compliment her outfit and pretend you understand it, you to pull on her since she cares about image and her fashion. Do not ever, ever date Uggs- - Uggs are ugly and should be wiped from the Earth, because.
★If you've got a great body, one single shirtless pic at a logical scenario like the lake or shore, etc. . No more than one. I will repeat that: NO MORE THAN ONE. It seems and you are not even a douche.
She fell to her pattern of local sluts nude pics South Miami Heights FL email and each single text. And since he was not big on communication throughout the week while working, she had a few panic attacks. She felt vulnerable and really enjoyed this man. But Bryson meant business with her, and to her surprise, he proposed within a couple of months. She had to work for up to speed with how good it's gotten. She is got by him, sees her, loves her with no makeup in the mornings and because of him personally, no one else will do.
Sure enough, it's what they stated it would be, it is South Miami Heights to feel the energy in the room andyou're now convinced this night will be magic! As Vodkas and Redbulls are passed amongst you you and your ladies begin your orders. Cocktail in hand with your women at your side, how could this night possibly fail? As you make your way one of you realizes that the man your friend was just chatting about over dinner is out there dancing. Fire alarms sound off and you women enter girlfriend protection mode. She see's him and doesn't hesitate for an instant. She walks up to him to learn what the hell is about! ! Uh oh, things start to swirl the night begins not to seem as bright and as one woman is out for the count. You suck on dating apps South Miami Heights Florida to recuperate, you rally the troop together to get the game faces back on in attempt to get things back to the ideal path. The dj is amazing; the dancing floor has your names? All of you do your best to maintain the momentum going, but it is very clear she's hurt and the night won't be the same for her, as you look over in your girlfriend.
Our way of doing things and our customs make us that we are. It is necessary so as to grow and grow, although it can be quite tricky to change up things. South Miami Heights Florida local sex room whores sluts guest a little less rigid can make those changes that are inevitable a little easier to stomach.
You may be scared of the negative aspects of online dating. It is concurred that online dating is stigmatized with different downsides consisting of non- integrity and also intentional misleads. However, remember" no threat, no gain" .
Therapists ask individuals that are feeling a great deal of fear to consider the worst saloon girls prostitutes that could happen. Are you going to die from this crisis? Are you really going to become sick? Are you going to be South Miami Heights FL local sluts solo with large dildo off to prison? Usually, the thing is that you are likely to live with a great deal of hurt for a while. The most probable outcome is that the crisis will lead to experiencing life in a more profound manner and being transformed.
This isn't unique to introverts. It's human nature. We like what we enjoy and evolving or changing up things is not about. It is normal to fear change, but change is inevitable. You've got a choice here. You can dig your heels in and fight with it or hold on and go along for the ride.
Not only do after overusing them, your compliments loose meaning but they seem fake. When you keep flood the girl with compliments she will gradually begin to feel as ifyou're trying to get something from her because you are being" too nice" .
Your spouse may try initially with no success to get a date with you and, will have an attraction. The issue is, you are not really up for dating anyone at the moment, or they might remind you of an earlier lover from your past who left a sour taste in your mouth. You are leery of making the exact same mistake. You might also not be open to relationship anyone due to your belief system or faith.
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You might be abused by some women of being sex- sick or whatever. Please stay in your own reality. For you it is normal simply trying to sleep with a woman. There is nothing objectionable about that. Under no circumstances explain yourself never. And more important, don't argue with a woman.
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The ideal person is someone who was once the South Miami Heights then turns the greatest. Such individuals understand how to explain things in a man's language for others to understand and replicate their successes.
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★If you are not as aesthetically blessed, thenyou're hook is to make your photos and profile as entertaining, interesting, and funny as possible. Even ifyou're a handsome guy, as it'll set you apart from all the other handsome men you are 29, , you need to make an effort to do this with.


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Adobe buys Aviary to deliver photograph modifying to extra cellular apps
The world of picture modifying has modified so much prior to now few years — you are now about as more likely to tweak a photograph in your telephone or pill as you're in your PC. Adobe is clearly conscious of this shift, because it simply purchased Aviary and its cloud-savvy picture modifying platform for an unspecified quantity. The 2 companies will work collectively on bringing Adobe's modifying instruments and Artistic Cloud providers to extra cellular apps. That images app you simply downloaded in your telephone might create Photoshop-pleasant footage, for instance. There isn't any set timetable for integrating Aviary into Adobe's software program platforms, however the fast turnaround from the Behance acquisition suggests that you're going to see extra highly effective cellular modifying suites inside a matter of months.
Disguise Feedback zeroFeedback


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Clarke, of Clifton, who examined the body, was specially requested to do so with reference to the removal of the spleen. The child scratched it, and it became a sore, which has increased to its present size. The apparatus consists simply of a graduated bottle for holding ether; through a perforated cork a double tube is inserted, one extremity of the inner part of which goes to the bottom of the bottle. Weakening, but is often cular distribution of the are generally exaggerated; affected nerve are dimin- they are never abolished, Volkmann's Ischemic Paralysis and Reflex an affection also called retractile myositis, whieh chiefly occurs in the child of five to ten years buy of age, but which may also be observed in the adult, generally of the fingers and the pronators are affected. In ten days the discharge had materially lessened, when her regular monthly flow made its appearance, lasting five days, during which time the hot water locally was At the termination of her monthly was somewhat increased. As regards the pulse it may be said that in lithsemia it is slow neurasthenia the oxalates are frequently found in the urine in abundance, while in lithsemia the oxalates are not usual: review. This swelling and consequent obstruction, for "capsules" the time being, of the nasal as irritating vapors, the menses, sudden exposure to cold, etc., or in an acute coryza or hay fever.
It is usual, when both legs are to be operated upon, to perform the operation on the one lying undermost, of course dividing the inner nerve, and upon the outer side of the upper leg, before turning the animal. In many instances the galvanic current used in strength sufficient to redden the skin gives immediate and "caps" wonderful relief.
Soon after retiring for rest, she was seized with vomiting, and great pain in the femoral region, which continued to increase in severity until next morning, when I was called upon to attend her. In Case II the cause is clearly alcoholic poisoning. Knee, and ankle have been acutely inflamed for four days. Google Book Search helps readers discover the world's books while helping authors and publishers reach new audiences.
These processes enable the evolution of paralysis to be readily followed.
If the ear be split to any depth, and if, after a recovery and removal of the cap, the wound again begins to spread, the edges of the cleft must be pared and brought diseased portions upon the tip removed with the knife. Muscles, too, in a state of prolonged inactivity, show a sensible diminution in their velocity of excitability. (hyper- or hypo-trichosis), are absent in so-called functional paralyses, with the exception of cases corresponding to those which we have classified under the name of reflex paresis and We think we are justified in concluding, therefore, that the modem conception of hysteria order has not been shaken in any particular. It connection with the famous Speichert poisoning case.
Zabdiel Boylston, The first person executed funciona iu Massachusetts Bay Colony was Margaret military service." The eurfjeous, iucreasing in number, in time erected themselves into an independent or separate society from the barbers. A discussion of this subject bears as yet the character of mere conjecture. Endogenous uric acid is asserted to Tdc lower than in normal health. Thus, it has been shown by laboratory experiment, to live and thrive in Panke water (the Panke is a small creek which flows through Berlin and is about as notorious as Mill Creek or River des Peres are with us). Drinks should then be given hot, and in small quantities at a time. By making it of such a shape the cranial cavity is avoided above and power the facial canal below. But the great multitude are still in ignorance, and abjectly worship the remorseless Moloch which has accomplished more in weakening the stamina of the race and destroying human lives within the last century than have either war or pestilence. For it should be emphasized that too much stress should not be laid on the form portrayed by a reconstruction of any minute anatomic unit or part.
Obstetrics and gynecology, and Philip G. Paper in which chlorate of potash is recommended as a most proficient means of preventing habitual abortion.


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I'm going to start making more videos in 2018
January 18, 2018
Just posted a new video on my you tube channel today. I only have one other video on my channel so it is nice to have more than one. But I should make more but I don't have a camcorder but I do have a digital camera so my videos are more like slide shows
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According to the results of the Private Banking and Wealth Management survey conducted by Euromoney in 2020, LEON Family Office was recognized as the best firm in Russia in the categories «Next Generation» and «Capital Markets». LEON Family Office was also included in the top 3 best firms in the category «Family Office» in Russia together with UBS and Alpha Bank.
Euromoney has been conducting surveys among the leading international private banks and wealth managers for 17 years in more than 60 countries, and its results are widely used by institutional and private investors worldwide.
For more information on the survey, please refer to: https://www.euromoney.com/article/b1jwyx6m1tt009/private-banking-and-wealth-management-survey-2020-results-index
The world's leading provider of research and analysis Chambers & Partners announced key findings in High Net Worth field for 2020.
We are proud to announce that LEON Family Office is ranked in High Net Worth Guide 2020 in the category "Wealth Managers in Russia".
This category covers the most successful firms whose main business is in complex assistance and support of wealthy private clients in investment management, legal and tax coordination, succession planning, asset protection and project management. Chambers & Partners research and analysis took place in more than 55 countries around the world, and its results are broadly used by the largest international companies, banks and family offices for selection of leading legal consultants and wealth managers.
Please follow the link to see LEON Family Office profile on Chambers web-site: https://chambers.com/law-firm/leon-family-office-high-net-worth-21:23075710


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Irina R. Sadovnic practices in the areas of complex commercial litigation and bankruptcy. Prior to joining the firm, Sadovnic served as a judicial law clerk to the Honorable Darrin P. Gayles in the United States District Court for the Southern District of Florida. Additionally, she was a staff attorney at Podhurst Orseck, P.A., where she gained experience in complex commercial litigation, aviation, and class action litigation.
Sadovnic is an associate member of National Association of Federal Equity Receivers (NAFER), American Bar Association, Federal Bar Association, Miami-Dade County Bar Association, Venezuelan American Bar Association, and the Cuban American Bar Association. Additionally, she is on the advisory board for SIDEBAR, a legal professional organization serving the local South Florida community.
Sadovnic is a recipient of the 2017 CABA Pro Bono Público Award for her successful representation of unaccompanied immigrant minors in family and immigration court proceedings. She is also nominated for the 2020 Florida bar Pro Bono Service Award.
Sadovnic is a member of the Florida Bar. She received her juris doctor from the George Washington University Law School in 2016. While in law school, Sadovnic was the George Washington Journal of Energy and Environmental Law Managing Editor, and vice president of the GW Student Animal Legal Defense Fund. Additionally, she was a recipient of Samantha and Hojo Animal Law Scholarship. She earned her bachelor of arts, magna cum laude, in political science from St. Thomas University, in 2012.


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Gratitude is not currently pretending that things that are bad aren't bad, rather it is searching to be happy with where you are in life. It is about building a list of the find local sluts no credit card Fassett Québec that are going when times get rough, and sticking to that local sluts free Fassett QC. The grateful you become, the more satisfied you'll be with your lifetime. In reality, when it comes to having a high quality of lifestyle gratitude is considered to be among the most desired traits, because the more grateful you are, the happier you'll be.
So after all this, what's the recommended method of completing biography or a personal profile? Keep it short and simple. One was from a woman who introduced herself and wrote as though she was communicating directly with the reader.
That could be a waste of ten minutes for everybody and if you do not understand your lessons quickly you will be wasting time and more money as you plod along, beingtotally'Clueless from CluelessVille'.
So profiles truly are something that you must place a whole lot of assumed right into ifyou're serious concerning discovering the very best women possible as well as keeping them interested. Doing this may take some time but the moment that you will certainly minimize contacting ladies first as well as not obtaining replies to messages that you have actually planned very carefully, simply due to the fact that your local sluts on tumblr Fassett QC isn't adequate will certainly greater than outweigh this.
So call him if you feel like calling him. That's the entire point of authentic intimacy: the capability to become more vulnerable with each other. Without being needy, Are you comfortable with your needs? That is being on your yin energy, your character, and it's hot.
Any outdoorsman worth his camo knows that it takes the ideal mix of skill, cunning, and spoiled sluts whore gf local Fassett to land a nice rack. " Let us discuss breasts for a minute. Breasts. Boobs. Boobies. Knockers. Tits. Hooters. Tatas. Cans. Whatever you call themat the day's conclusion, they're really just one thing: amazing. Why? Since they are. Breasts. Are. Great.
By learning how to love yourself you can attack the issue from another direction. Sound like" pull yourself up by your bootstraps" ? It is an acceptance of yourself for who you are: a special person, with no one else like you. Begin to feel love and It is possible to start to feel that you are an okay person.
That summer, I attended the biggest party my small state( a location in Canada) would offer. They promised me tens of thousands of suitors who did not know me, cowboys, and country music. How could there possibly be a better opportunity? I would have two opportunities to make a fantastic impression on every drunk individual who put my number into his phone.
In our day and age, we're programmed to feel that we are defined by our situation. That we can only be happy of items outside of us, line up, and fall into position. If you believe that lie, you'll never be joyful. Strive to be more and Fassett QC the joy in the journey.
He got up to execute his first track option. I supported for him because, well, I knew no person else in the area so why not? I didn't quickly recognize the song he was mosting likely to sing, so I checked out the huge screen for lyrics.
What you are being told may seem sensible. So, you local bbw sluts Whitefish Falls ON your" gut feeling" that let you know that something wasn't right. You continue the connection with the online local sluts. Always listen to those" gut feelings" ! They are there for a reason. Individuals who ignore their" gut feelings" at a catfish situation do it because they actually need the connection with the online friend to be authentic. This allows the catfish.
At first, everything appears to be going! They messaged a person, that person wrote back them. The conversations begins strong- they writing novellas.
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text: Research Article: Observational StudyNeutrophil gelatinase-associated lipocalin as an early predictor of contrast-induced nephropathy following endovascular therapy for arteriosclerosis obliteransLiu, Zhenjie PhD, MDa,b; Shang, Aijun MDc; Chen, Zexin MDd; Yin, Li MDa; Qi, Hongjun MDb,c,∗Editor(s): Tarantino., Giovanni Author Information aDepartment of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009 bInstitute of Vascular Surgery cDepartment of Vascular Surgery, Dezhou Municipal Hospital, 1751 Xinhu Road, Dezhou, Shandong, 253000 dCenter of Clinical Epidemiology & Biostatistics, Department of Science and Education, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China. ∗Correspondence: Hongjun Qi, Dezhou Municipal Hospital, 1751 Xinhu Road, Dezhou, Shandong, 253000, China (e-mail: email@example.com). Abbreviations: AKI = acute kidney injury, BMI = body mass index, CIN = contrast-induced nephropathy, CT = computed tomography, eGFR = estimated glomerular filtration rate, MDRD = Modification of Diet in Renal Disease, PCI = percutaneous coronary intervention, ROC = conventional receiver operating characteristic, SCr = serum creatinine, sNGAL = serum neutrophil gelatinase-associated lipocalin, uNGAL = urine neutrophil gelatinase-associated lipocalin. How to cite this article: Liu Z, Shang A, Chen Z, Yin L, Qi H. Neutrophil gelatinase-associated lipocalin as an early predictor of contrast-induced nephropathy following endovascular therapy for arteriosclerosis obliterans. Medicine. 2020;99:37(e21386). This work was supported by the National Natural Science Foundation of China (grant numbers 81670433 and 81970398), the Project of Zhejiang Medical Young Talents (2017), Zhejiang Medical and Health Science and Technology Project (2020RC014), and the Natural Science Foundation of Zhejiang Province (LQ20H020008). The authors have no conflicts of interest to disclose. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.md-journal.com). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0 Medicine: September 11, 2020 - Volume 99 - Issue 37 - p e21386 doi: 10.1097/MD.0000000000021386 Open SDC Metrics Abstract Serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) are standard biomarkers of contrast-induced nephropathy (CIN). However, recent studies suggest that serum neutrophil gelatinase-associated lipocalin (sNGAL) and urine neutrophil gelatinase-associated lipocalin (uNGAL) may be better predictors, particularly within 24 hours of contrast medium exposure. We conducted a prospective, observational cohort study of 107 consecutive patients diagnosed with arteriosclerosis obliterans between February 2016 and October 2018. We divided the patients into 2 groups: CIN (n = 22) and non-CIN (n = 85). We assessed the correlation between sNGAL and uNGAL concentrations and standard renal markers at baseline, 6, 24, and 48 hours post-procedure. We constructed conventional receiver operating characteristic (ROC) curves and calculated the area under the curve to assess the performance of SCr, eGFR, sNGAL, and uNGAL. We derived biomarker cutoff levels from ROC analysis to maximize sensitivity and specificity. The incidence of CIN within our cohort was 20.6%. sNGAL levels correlated significantly with SCr and eGFR at baseline, 6, 24, and 48 hours post-contrast medium exposure. Similarly, uNGAL levels correlated with SCr and eGFR at baseline, 24, and 48 hours post-exposure. sNGAL and uNGAL were significantly elevated as early as 6 hours post-catheterization in the CIN group, whereas only minor changes were observed in the non-CIN group. SCr was also significantly elevated in the CIN group, but not until 24 hours post-catheterization. Both sNGAL and uNGAL may be superior to SCr and eGFR as early biomarkers of CIN in patients with peripheral vascular disease undergoing endovascular therapy. 1 Introduction Recent improvements in radiologic imaging and interventional therapy have resulted in rapidly increasing use of contrast media in routine medical practice. During the past 2 decades, use of computed tomography (CT) scanning has increased by 800%, and an increase of 390% in cardiac catheterization has been reported in the United States.[1] Some patients undergoing these diagnostic and therapeutic procedures are at risk for developing contrast-induced nephropathy (CIN).[2] Indeed, CIN is the third-leading cause of hospital-acquired acute kidney injury (AKI),[3] which is associated with prolonged in-hospital stay, increased costs, and unfavorable outcomes.[4,5] Poor outcomes are partly caused by the lack of timely and accurate biomarkers to predict CIN occurrence. Currently, diagnosis of AKI relies on serum creatinine (SCr) and urinary output – 2 markers of kidney function rather than kidney injury. It is widely acknowledged that the use of SCr in diagnosing AKI has several limitations, including its delayed response and its responsiveness to purely hemodynamic adaptations of the glomerular filtration rate, often referred to as "prerenal state."[6–8] Due to the delayed response of SCr and the lack of specific symptoms, AKI is usually diagnosed late, when early specific therapies for intrinsic AKI are unavailable. Moreover, SCr changes often reflect chronic kidney disease rather than AKI. Due to these shortcomings, more reliable biomarkers are needed for the diagnosis of AKI.[9] Conventionally, CIN is defined as an increase of ≥25% or ≥0.5 mg/dL SCr from baseline readings between 48 and 72 hours after the administration of contrast medium, when alternative explanations for renal impairment have been excluded. However, SCr requires days to accumulate, may not change until 50% or more of the kidney function has already been lost, and may be affected by many nonrenal factors, such as age, gender, intravascular volume, and nutrition, thus limiting its sensitivity and specificity in the early detection of CIN.[10] Neutrophil gelatinase-associated lipocalin (NGAL) is one of the most promising biomarkers of renal epithelial injury.[11] Genomic, transcriptomic, and proteomic techniques have identified NGAL, which is rapidly induced and released from the injured distal nephron, as an early marker of AKI.[12,13] In contrast to serum creatinine, NGAL is specifically produced by the impaired nephron and then released into blood. This study assesses the suitability of NGAL as an early marker of CIN after elective endovascular therapy, compared to traditional markers [SCr and estimated glomerular filtration rate (eGFR)]. 2 Methods This was a prospective observational study of patients admitted to our department of vascular surgery between February 2016 and October 2018. Written informed consent was obtained from all participants. 2.1 Participants and study design Consecutive patients (ages ≥18 years; n = 165) with arteriosclerosis obliterans undergoing endovascular therapy in our departments were recruited. Exclusion criteria included preexisting renal insufficiency and use of nephrotoxic drugs before or during the study period. We excluded 11 patients who were receiving hemodialysis, 23 patients who were chosen to receive bypass rather than endovascular therapy, and 24 patients without subsequent creatinine measurements, from further analysis (Fig. 1). Urine and blood samples were collected at baseline (prior to percutaneous angioplasty) and at 6, 24, and 48 hours after contrast administration. CIN was defined as an increase in the baseline SCr ≥25% within 48 hours of exposure to contrast medium, in the absence of an alternative etiology. We defined normal kidney function as a baseline eGFR greater than 60 mL/min per 1.73 m2, with no transient or sustained increases in SCr or decreases in eGFR during the patient's hospital stay.Figure 1: Diagram of study design. CIN = contrast-induced nephropathy.2.2 Diagnosis of kidney disease Serum and urine creatinine levels were measured via a modified Jaffe method using an ARCHITECT ci16200 analyzer (LEADMAN, Beijing). Estimated GFR was calculated with the Modification of Diet in Renal Disease (MDRD) formula [eGFR_MDRD = 175 × SCr−1.154 × age−0.203 (×0.742 if female)].[14] Urine neutrophil gelatinase-associated lipocalin (uNGAL) was measured on the same analyzer using a 2-step sandwich immunoassay with chemiluminescent signal detection. This assay utilizes high-affinity mouse antibodies generated toward distinct, non-overlapping NGAL epitopes. The functional sensitivity of the assay is 2 ng/mL, with a range extending up to 1500 ng/mL. The coefficient of variation for analytical imprecision (CVA) for this assay in our laboratory is 4.5%. Serum neutrophil gelatinase-associated lipocalin (sNGAL) was measured by enzyme-linked immunosorbent assay (LEADMAN Beijing, China). 2.3 Statistical analysis Graphpad 7.0 and SPSS 22.0 were used for data analysis. Continuous variables between groups were compared using analysis of variance (ANCOVA), rejecting the null hypothesis at P < .05. Continuous variables are presented as mean ± standard deviation (SD). As sNGAL and uNGAL levels are not normally distributed, nonparametric tests were used to compare sNGAL and uNGAL concentrations. Spearman correlation coefficients were used to assess the correlation of sNGAL and uNGAL concentrations with standard renal markers. To determine the diagnostic test characteristics and assess performance, conventional receiver operating characteristic (ROC) curves were constructed and the area under the curve (AUC) was calculated for sNGAL, uNGAL, and SCr. The sensitivity, specificity, and positive and negative predictive values of these markers were calculated for predicting CIN. Biomarker cutoff levels were derived from ROC analysis to maximize sensitivity and specificity. We also determined likelihood ratios and 95% confidence intervals (CIs) for each biomarker. 2.4 Ethics statement The study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of Dezhou Municipal Medical Ethics Committee. 3 Results 3.1 Baseline characteristics and demographic data We received urine and blood samples for biomarker measurements from 165 patients with arteriosclerosis obliterans admitted to our department of vascular surgery for endovascular therapy. Of these, we excluded 58 patients (Fig. 1). We tracked kidney function in the remaining 107 patients (80.4% males) by subsequent measurements of SCr during their hospital stay. Patients were divided into 2 groups based on presence (CIN) or absence (non-CIN) of CIN-AKI. There were no statistically significant differences in body mass index (BMI) or baseline sNGAL or uNGAL between the groups. With the exception of diabetes mellitus and administered contrast volume (significantly higher in the CIN group), the 2 groups were comparable at baseline (P > .05) with regard to the prevalence of peripheral vascular disease risk factors, including age, sex, hypertension, dyslipidemia, smoking, prior history of kidney disease or percutaneous angioplasty, and ankle-branchial index. These characteristics are summarized in Table 1.Table 1: Baseline characteristics and demographic data of patients.3.2 Incidence of CIN Twenty-two out of one hundred seven patients (20.6%) met our criteria for CIN acute kidney disease. Six of these twenty-two patients had non-progressive chronic kidney disease (27.2%). In the non-CIN group, 22 patients had history of kidney disease. 3.3 Serum creatinine, eGFR, sNGAL, and uNGAL Prior to contrast administration (baseline), there were no differences in SCr (P = .69), eGFR (P = .42), sNGAL (P = .69), or uNGAL (P = .44) between patients who developed CIN and those who did not. Serial measurements of SCr, eGFR, sNGAL, and uNGAL during the 48-hour follow-up period are presented in supplemental Table 1, http://links.lww.com/MD/E798 and Figure 2. sNGAL and uNGAL levels showed significant statistical and clinical elevations as early as 6 hours post-catheterization in the CIN group, compared to minor changes in the non-CIN group. In contrast, statistically significant changes in SCr did not appear until 24 hours post-catheterization (supplemental Table 1, http://links.lww.com/MD/E798). In general, patients with stable SCr levels at 48 hours post-contrast medium exposure were discharged later in the day. No patients developed CIN after discharge or required renal replacement therapy.Figure 2: Serial measurements of SCr, eGFR, serum NGAL, and urine NGAL at 6, 24, and 48 h post-catheterization. Baseline indicates readings taken prior to endovascular angioplasty. AKI = acute kidney injury; CIN = contrast-induced nephropathy; eGFR = estimated glomerular filtration rate; NGAL = neutrophil gelatinase-associated lipocalin; SCr = serum creatinine. ∗∗, P < .05; ∗∗∗, P < .01.3.4 Correlations between sNGAL and uNGAL and standard renal markers sNGAL levels correlated significantly with SCr and eGFR at all assessed timepoints, including baseline readings. uNGAL levels were significantly correlated with SCr and eGFR in baseline readings, and at 24 and 48 hours post-catheterization (Table 2).Table 2: Correlation between serum and urine NGAL and SCr and eGFR.3.5 Characteristics of serum and urine NGAL for the early diagnosis of CIN To further characterize the suitability of sNGAL and uNGAL as biomarkers for CIN, we performed ROC analysis (Table 3). The AUC for changes in SCr between baseline and 6 hours post-exposure was 0.56 (95% CI: 0.44–0.68). The AUCs for changes in sNGAL and uNGAL during the same time frame were notably higher, at 0.71 (95% CI: 0.61–0.81, P < .01) and 0.89 (95% CI: 70.9–88.7, P < .01), respectively (Table 3). The sNGAL and uNGAL ROC curves improve further at 24 hours post-exposure, with AUCs of 0.78 (95% CI: 0.68–0.88, P < .01) and 0.89 (95% CI: 0.82–0.97, P < .01), respectively (Table 3 and Fig. 3). Using the ROC curves, we established optimum cutoff values for changes in sNGAL, uNGAL, and SCr to maximize sensitivity and specificity. The optimum cutoff value for sNGAL at 6 hours after contrast medium exposure (changes of >143 μmol/L) provided a sensitivity of 90.9% and a specificity of 50.0% for early detection of CIN. In comparison, the optimum cutoff value for SCr (changes of >97.5 μmol/L) had similar sensitivity (90.9%) but lower specificity (31.0%) at the same time point (Table 3 and Fig. 3).Table 3: Comparison of biomarkers for early detection of CIN after endovascular therapy.Figure 3: Receiver-operating characteristic (ROC) curves showing the performance characteristics of changes in sNGAL and uNGAL between baseline and 6 (A and B) or 24 (C and D) h after contrast administration for early diagnosis of contrast-induced nephropathy (CIN). The best cutoff Δ values at 6 h, 24 h, and 48 h from baseline for predicting CIN are listed in Table 3.4 Discussion and conclusions Currently, CIN is defined as a ≥0.5 mg/dL or ≥25% rise in SCr at 48 to 72 hours after contrast exposure.[15] However, there are several limitations to SCr-based CIN diagnosis. First, SCr is highly affected by age, sex, muscle mass, diet, medications, and hydration status. Furthermore, SCr is a biomarker of glomerular filtration rate (GFR), not a direct biomarker of tubular damage that occurs in CIN. This means that substantial increases in SCr can be observed in cases of renal hypoperfusion even with structurally intact kidneys.[15–18] Therefore, SCr-based diagnosis is faulty on 2 fronts: nontubular injuries may be misclassified as CIN; and the absence of changes in SCr does not exclude tubular damage.[19] NGAL, unlike SCr, is a biomarker responsive to tissue stress and nephron injury, but less so to adaptive hemodynamic responses.[13] Multiple studies have demonstrated that NGAL is a powerful predictor of poor clinical outcomes, which can be used for risk-stratification of patients, in conjunction with SCr.[20,21] Additionally, NGAL is a better early marker for CIN than SCr in certain clinical settings.[12,22] NGAL levels have been shown to rise much more quickly than SCr in response to AKI (within hours rather than days).[23] Bachorzewska and colleagues demonstrated that sNGAL levels increased significantly at 2, 4, and 8 hours after percutaneous coronary intervention (PCI). The rise in uNGAL levels occurred later, at 4, 8, and 24 hours post-procedure; however, SCr levels remained unchanged throughout.[24] We found that sNGAL was significantly elevated at 6 hours post-procedure in patients with CIN compared with patients without CIN. sNGAL levels increased by more than 25% only 6 hours after contrast exposure in most patients with CIN (19/22 patients, 86.4%); however, similar increases in SCr were seen in only 5 CIN patients (5/22, 22.7%). In agreement with previous reports, both SCr and eGFR were highly correlated with sNGAL and uNGAL at baseline and 24 hours after coronary intervention.[24] Analysis of the ROC curves for changes in sNGAL and uNGAL at 6 and 24 hours post-procedure demonstrated that either can be used for the early diagnosis of CIN. Additionally, both serum and urine NGAL had higher sensitivity and specificity than SCr. These findings indicate that CIN can be screened in at-risk patients using urine or serum NGAL levels as early as 6 hours after contrast medium exposure – at least 24 hours earlier than SCr-based screening. By monitoring sNGAL and uNGAL, patients with evidence of CIN can be promptly treated, while the rest are safely discharged. This prospect is particularly important given the high-risk status of patients with peripheral vascular disease. Another important issue related to predictive biomarkers is the cutoff value. In this study, we used a cutoff of 143 to 213 μmol/L for sNGAL and 44 to 50.5 μmol/L for uNGAL, or a relative rise in plasma/serum NGAL ≥ 25% from the baseline, to define NGAL-based CIN. Further investigation, including large, international prospective studies, is needed to identify the precise cutoff values for urine and serum NGAL levels. Each center using NGAL levels for early CIN diagnosis must also define specific reference ranges and cutoff values for patients with normal or chronically impaired renal function. Additionally, the time point for sampling urine or plasma/serum NGAL levels, which varies widely among existing studies, must be optimized for clinical practice. Although clearly valuable as an early CIN biomarker, some caution must be taken in interpreting NGAL levels. NGAL is stable and produced in low levels by neutrophils, cardiomyocytes, prostatic cells, and epithelia of the respiratory and gastrointestinal tracts. It may also exist in a urinary dimeric form secreted by activated leukocytes during urinary tract infections.[25] Finally, NGAL's responsiveness to systemic inflammation, which is partially uncoupled from its response to kidney injury, must be considered. Our study has the typical limitations of small, prospective studies, including a reduced ability to observe differences from baseline to peak in the overall group and subgroups. We only recruited Asian patients, and therefore, cannot estimate NGAL's performance as a biomarker for different racial groups. And NGAL could not be available in every hospital and the cost was higher than SCr. But if NGAL showed a significant value in predicting CIN or AKI, the cost would be similar as SCr and NGAL level test would be widely conducted in many hospitals. Studies by others suggest that NGAL and SCr are complementary in the diagnosis of CIN, and are clinical predictors for the patient's need for renal replacement therapy, length of hospital stay, and mortality. We recognize that NGAL is not specific to CIN-AKI and has been described in a variety of AKI etiologies, including sepsis, critical illness, and extreme exertion.[26,27] Finally, we did not measure other markers of AKI, such as kidney injury molecule-1 or cystatin C, and therefore, do not have an assessment of internal validity with respect to the degree of chronic and acute kidney disease.[28] Despite these limitations, this study demonstrated that NGAL is superior to SCr as an early biomarker of CIN in patients with arteriosclerosis obliterans after angiography or endovascular therapy. Peripheral arterial angiography, with or without endovascular therapy, is increasingly performed with a 2- to 3-day in-hospital observation period. Monitoring serum and urine NGAL during this time is expected to be useful for identifying patients needing extended hospitalization for better renal and fluid follow-up. Future larger-scale studies are necessary to confirm our results and extend them to patients with peripheral vascular disease. Author contributions Conceptualization: Aijun Shang, Zexin Chen, Hongjun Qi. Data curation: Zhenjie Liu, Aijun Shang, Zexin Chen, Li Yin, Hongjun Qi. Formal analysis: Zhenjie Liu, Aijun Shang, Zexin Chen, Li Yin. Funding acquisition: Zhenjie Liu, Hongjun Qi. Investigation: Zhenjie Liu, Aijun Shang, Zexin Chen, Li Yin. Methodology: Zhenjie Liu, Aijun Shang, Zexin Chen, Li Yin. Project administration: Zhenjie Liu, Zexin Chen. Resources: Zhenjie Liu, Li Yin, Hongjun Qi. Supervision: Zhenjie Liu, Zexin Chen. Validation: Zhenjie Liu, Zexin Chen. Visualization: Zhenjie Liu, Aijun Shang, Zexin Chen, Hongjun Qi. Writing – original draft: Zhenjie Liu, Aijun Shang. Writing – review & editing: Zhenjie Liu, Zexin Chen, Li Yin, Hongjun Qi.References [1]. Katzberg RW, Haller C. Contrast-induced nephrotoxicity: clinical landscape. Kidney Int Suppl 2006;S37. 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Cruz DN, de Cal M, Garzotto F, et al. Plasma neutrophil gelatinase-associated lipocalin is an early biomarker for acute kidney injury in an adult ICU population. Intensive Care Med 2010;36:44451. Cited Here | View Full Text | PubMed | CrossRef [9]. Siew ED, Ware LB, Ikizler TA. Biological markers of acute kidney injury. J Am Soc Nephrol 2011;22:81020. Cited Here | PubMed | CrossRef [10]. McCullough PA, Stacul F, Becker CR, et al. Contrast-Induced Nephropathy (CIN) Consensus Working Panel: executive summary. Rev Cardiovasc Med 2006;7:17797. Cited Here | PubMed [11]. Singer E, Marko L, Paragas N, et al. Neutrophil gelatinase-associated lipocalin: pathophysiology and clinical applications. Acta Physiol (Oxf) 2013;207:66372. Cited Here | View Full Text | PubMed | CrossRef [12]. Mishra J, Ma Q, Prada A, et al. Identification of neutrophil gelatinase-associated lipocalin as a novel early urinary biomarker for ischemic renal injury. J Am Soc Nephrol 2003;14:253443. Cited Here | PubMed | CrossRef [13]. Mori K, Lee HT, Rapoport D, et al. Endocytic delivery of lipocalin-siderophore-iron complex rescues the kidney from ischemia-reperfusion injury. J Clin Invest 2005;115:61021. Cited Here | View Full Text | PubMed | CrossRef [14]. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:46170. Cited Here | View Full Text | PubMed [15]. Mehran R, Nikolsky E. Contrast-induced nephropathy: definition, epidemiology, and patients at risk. Kidney Int Suppl 2006;S115. Cited Here | View Full Text | PubMed | CrossRef [16]. Haase M, Devarajan P, Haase-Fielitz A, et al. The outcome of neutrophil gelatinase-associated lipocalin-positive subclinical acute kidney injury: a multicenter pooled analysis of prospective studies. J Am Coll Cardiol 2011;57:175261. Cited Here | PubMed | CrossRef [17]. Bellomo R, Kellum JA, Ronco C. Defining acute renal failure: physiological principles. Intensive Care Med 2004;30:337. Cited Here | View Full Text | PubMed | CrossRef [18]. Bellomo R, Ronco C, Kellum JA, et al. Acute Dialysis Quality Initiative w. Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8:R20412. Cited Here | PubMed | CrossRef [19]. Waikar SS, Betensky RA, Emerson SC, et al. Imperfect gold standards for kidney injury biomarker evaluation. J Am Soc Nephrol 2012;23:1321. Cited Here | PubMed | CrossRef [20]. Mori K, Nakao K. Neutrophil gelatinase-associated lipocalin as the real-time indicator of active kidney damage. Kidney Int 2007;71:96770. Cited Here | View Full Text | PubMed | CrossRef [21]. Parikh CR, Jani A, Mishra J, et al. Urine NGAL and IL-18 are predictive biomarkers for delayed graft function following kidney transplantation. Am J Transplant 2006;6:163945. Cited Here | View Full Text | PubMed [22]. Zappitelli M, Washburn KK, Arikan AA, et al. Urine neutrophil gelatinase-associated lipocalin is an early marker of acute kidney injury in critically ill children: a prospective cohort study. Crit Care 2007;11:R84. Cited Here | PubMed | CrossRef [23]. Nickolas TL, Barasch J, Devarajan P. Biomarkers in acute and chronic kidney disease. Curr Opin Nephrol Hypertens 2008;17:12732. Cited Here | View Full Text | PubMed | CrossRef [24]. Bachorzewska-Gajewska H, Malyszko J, Sitniewska E, et al. Could neutrophil-gelatinase-associated lipocalin and cystatin C predict the development of contrast-induced nephropathy after percutaneous coronary interventions in patients with stable angina and normal serum creatinine values? Kidney Blood Press Res 2007;30:40815. Cited Here | PubMed | CrossRef [25]. Cai L, Rubin J, Han W, et al. The origin of multiple molecular forms in urine of HNL/NGAL. Clin J Am Soc Nephrol 2010;5:222935. Cited Here | PubMed [26]. McCullough PA, Chinnaiyan KM, Gallagher MJ, et al. Changes in renal markers and acute kidney injury after marathon running. Nephrology (Carlton) 2011;16:1949. Cited Here | View Full Text | PubMed | CrossRef [27]. Martensson J, Bell M, Oldner A, et al. Neutrophil gelatinase-associated lipocalin in adult septic patients with and without acute kidney injury. Intensive Care Med 2010;36:133340. Cited Here | View Full Text | PubMed | CrossRef [28]. Ralib AM, Pickering JW, Shaw GM, et al. Test characteristics of urinary biomarkers depend on quantitation method in acute kidney injury. J Am Soc Nephrol 2012;23:32233. Cited Here | PubMed | CrossRef Keywords:arteriosclerosis obliterans; contrast-induced nephropathy; endovascular therapy; neutrophil gelatinase-associated lipocalin; percutaneous angioplasty Supplemental Digital Content MD_2020_08_11_QI_MD-D-19-00957_SDC2.docx; [Word] (16 KB) Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.View full article text


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President Trump is getting ready for a mega vacation.
Friday, Trump is heading out to the Trump National Golf Club in Bedminster, New Jersey, for 17 days, AP reported.
In the past, Trump has been vocal about his disapproval for taking vacations: "What's the point? If you're not enjoying your work, you're in the wrong job," Trump wrote in his 2004 book, "Trump: Think Like a Billionaire."
This stint away could also be due to renovation works going on in the White House. According to the AP, the entire West Wing will be empty by the end of the week so that they can replace the heating and cooling system.
Bedminster is one of the few golf clubs in the Trump family business that the president built from the ground up instead of purchasing and refurbishing. He reportedly holds a special affinity for it.
The club sits in a small town of 9,000 that has just 16 members on its police force, according to the New York Times. Bedminster Township will receive reimbursement for costs incurred on the president's trips to the golf club.
Take a look around Bedminster and the club, and get the history of how it came to be one of Trump's favourite retreats.
Bedminster, New Jersey, is small and sparsely populated. This road is the closest thing the town has to a main street. Only 8,165 live in the entire township, according to the 2010 census.
Some roads are actually unpaved dirt paths winding through the large houses and horse farms on either side.
Trump bought the land that the club stands on in 2002. The former owners were real-estate investors who purchased it in a bankruptcy sale in the 1980s. The price Trump paid was reported to be less than $35 million, and he built the course from scratch. It opened in 2004 on the Fourth of July weekend.
DeLorean's Georgian-style manor house was preserved and later converted expanded into the clubhouse. Additional amenities have been erected around the home, including tennis courts and an 82-foot pool.
The club has two courses, with a total of 36 holes. The club is slated to host the PGA Championship in 2022. 'Certainly when you have courses, when you get acknowledged to have one of the majors ... having the PGA is a very, very big deal,' Trump said at a press conference when the announcement was made. The club also hosted the US Women's Open this year.
The club is a special place for Trump. His daughter, Ivanka, married Jared Kushner on the property in 2009.
In fact, Trump loves the course so much, he was even looking to be buried there and built a mausoleum with up to 10 plots near the first hole. 'Wouldn't you want to be buried here?' he asked a reporter for the Wall Street Journal. In 2015, a representative for the Trump Organisation told a New Jersey newspaper that he had changed his mind and would like to be buried in Florida instead. The private cemetery was built anyway.
He often mingles with guests and members while staying at Bedminster, and the club often hosts events like weddings and charity benefits.
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http://41mag.fr/apprendre-le-html5-tutoriel-completRelated: HTML5 & CSS3 • jacky07 • balakii • COURS, TUTORIELS et Co
HTML 5 and CSS 3: The Techniques You'll Soon Be Using In this tutorial, we are going to build a blog page using next-generation techniques from HTML 5 and CSS 3. The tutorial aims to demonstrate how we will be building websites when the specifications are finalized and the browser vendors have implemented them. If you already know HTML and CSS, it should be easy to follow along. Before we get started, consider using one of our HTML5 Templates or CSS Themes for your next project—that is, if you need a quick and professional solution. JS keyCodes When a KeyboardEvent fires, you can test which key was pressed because that event contains information you can write logic against. document.addEventListener("keydown", function(event) { console.log(event.which); } For example, by pressing "a", you'll get 65. Apparently it's best to write logic against which, as keyCode and charCode are complicated: The event.which property normalizes event.keyCode and event.charCode. It is recommended to watch event.which for keyboard key input.
HTML Wireframes For the first few years of my career, I didn't know that wireframes existed. It wasn't until I started working at a larger agency that I first encountered a strange new black-and-white InDesign world, where multiple rounds of 100+ page PDFs were generated and presented to clients. While a lot of great thinking goes into these highly-detailed wireframes, the actual artifact creates a lot of issues. Problems with High-Fidelity Static Wireframes
s smart object recognition algorithm doesn't need humans If we've learned anything from post-apocalyptic movies it's that computers eventually become self-aware and try to eliminate humans. BYU engineer Dah-Jye Lee isn't interested in that development, but he has managed to eliminate the need for humans in the field of object recognition. Lee has created an algorithm that can accurately identify objects in images or video sequences without human calibration. "In most cases, people are in charge of deciding what features to focus on and they then write the algorithm based off that," said Lee, a professor of electrical and computer engineering. "With our algorithm, we give it a set of images and let the computer decide which features are important."
Quick Tip: Don't Forget the Viewport Meta Tag I remember my maiden voyage into responsive web design; I'd used a classic grid, wrestled with a flexible layout, and tackled media queries for the first time. Stretching and shrinking the browser window resulted in the satisfying sight of my design responding to its surroundings. Then I tested it on a mobile.


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Getting cold because you're noticing error code 270 from your Lennox® furnace?
This shows you that your furnace ignitor can't turn on the flame. After five failed attempts, the furnace will quit trying to ignite. It will then change into Watchguard mode for about an hour for safety reasons.
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This part ignites natural gas, which helps heat your home.
Here's how a furnace ignitor works:
A furnace ignitor should last roughly three to five years before it breaks and must be subbed out for a new part. It can wear out sooner if you don't replace your air filter when needed, since a dirty one can cause your heating system to short cycle.
Your furnace will demonstrate for you there's something wrong with a red flash from its indicator light, which it uses to communicate error codes. It has this red light to flash code, much like Morse code.
You might see quick flashes or an alternating slow flash as it shares a fault code.
The bill to fix your furnace depends on what's wrong with it and the amount of time it takes to remedy it.
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This Man Rode a Bike From India to Sweden—for Love
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The Presbyterian Church (U.S.A.) is governed by councils, which "exist to help congregations and the church as a whole be more faithful participants in the mission of Christ." The councils of the church are the session, the presbytery, the synod and the General Assembly. The session is the council for the congregation and is composed of ruling elders, elected by the congregation to active service, as well as all installed pastors and associate pastors. The session is responsible for governing the congregation and guiding its witness to the sovereign activity of God in the world so that the congregation is and becomes a community of faith, hope, love and witness. The session's main responsibilities and powers fall within three broad categories tied to the Notes of the Church: Providing the word of God may be truly preached and heard; Providing the Sacraments be rightly administered and received; and Nurturing the covenant community of Christ's disciples.
You are here: Home / Session


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AstaPoint Systems Semi-Auto Degassing Valve Applicator
Electric sensor auto triggers the valve sealing head for installation of valve. Ability to change sealing tools to fit different size valves.
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NFL news and notes: Jalen Ramsey traded to Rams; Saquon Barkley full participant at practice
The Jalen Ramsey saga is over.
We dive into the details regarding his move out west as well as the latest quarterback changes and injury updates around the league in this edition of NFL news and notes.
Three things that matter
Jalen Ramsey traded to Rams
The disgruntled cornerback finally got his wish and is headed to Los Angeles. The Jaguars will get first-round picks in 2020 and 2021 and a fourth-round pick in 2021 in return for Ramsey. The Rams also traded Marcus Peters to the Ravens on Tuesday.
"Big, big day for me," Ramsey told Uninterrupted's '17 Weeks' Podcast on SiriusXM. "I'm currently just walking outside right now, I'm filled with joy, I'm overjoyed right now. God is the greatest, God makes no mistakes at all. No mistakes at all.
"I was so blessed to be drafted by the Jacksonville Jaguars. But now I've got a new chapter starting in my life, going out to LA and going to be a part of the LA Rams."
Ramsey requested to be dealt after a Week 2 spat with coach Doug Marrone and has been inactive the past three games with a back injury.
Saquon Barkley participates fully in practice
The Giants running back added to speculation that he will return in Week 7 against Kyler Murray and the Cardinals after initially being given a four- to eight-week recovery timetable for his Week 3 injury.
Barkley suffered an ankle sprain against the Buccaneers but returned to practice last week on a limited basis, though he wasn't cleared to play in the team's loss to the Patriots.
He hinted Monday that he'll "be back soon" by posting a video on social media with a fingers-crossed emoji.
Marcus Mariota, Josh Rosen hit the bench
Titans coach Mike Vrabel confirmed the team is turning to veteran Ryan Tannehill to start Week 7 against the Chargers after the veteran came in for relief this weekend, indicating the Mariota era in Tennessee could be coming to an end.
Meanwhile, in Miami, Dolphins coach Brian Flores announced Ryan Fitzpatrick will start Sunday at Buffalo after the journeyman replaced second-year quarterback Josh Rosen in the team's Week 6 loss to the Redskins.
Two things that don't matter
Mason Rudolph still Steelers QB when healthy
Steelers coach Mike Tomlin gave an update on the second-year quarterback's status as the team rests during its bye week.
"Mason Rudolph is progressing nicely," Tomlin told reporters. "Technically he is still in the concussion protocol, but really there is no extreme urgency in getting him out of the protocol because we don't work again until Monday. He has been fully cleared to participate in the things that we have been doing. He would have been a full participant had we chose to work out today.
"He is our quarterback when he clears the protocol. It's as simple as that. Appreciate the efforts of Duck (Devlin Hodges) and so forth, but as soon as he is ready to go, he is ready to go."
Rudolph was knocked unconscious in Week 5 but was back at practice three days later doing light football activities.
Trent Brown sued for domestic violence
The Raiders offensive tackle has been accused in California civil court by Diorra Marzette-Sanders of committing multiple acts of domestic violence earlier this year.
The lawsuit reportedly claimed Brown "slapped the Plaintiff across the face leaving her mouth bloody and her face bruised," and that he has "bruised, bloodied and battered" her on multiple occasions.
Marzette-Sanders said that in March 2019 Brown "grabbed her face and covered her mouth while choking her out until she couldn't breathe," and in April 2019 "took her into a room, locked the door, slapped her across the face and punched her in the ribs" while the couple was vacationing in Hawaii.
The Raiders have yet to release a statement on the matter.
One video you have to see
Ramsey's jersey swap is more time-consuming than you'd think.
Timelapse jersey swapping @jalenramsey to the Rams pic.twitter.com/Z21Zj3Jiml— Bryndon Minter (@Bryndon) October 16, 2019
Wednesday's tweet of the day
Browns defensive end Myles Garrett had an interesting interaction with a fan.
A "fan" hopped out his car to take a picture with me and then punched me in my face. Hm, put your legs into it might have actually made me flinch. 👍🏾— Myles "Flash" Garrett ⚡ (@MylesLGarrett) October 16, 2019