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Archive for September 2013
Pensioners Warned Over Boiler Insurance Scam
ELDERLY people are being warned not to feel pressurised into giving their credit or debit card details to cold callers following a series of complaints about a company that attempts to sell them boiler insurance products they don't need.
The company, Heat Plan Utilities, based in Surrey, calls elderly people to tell them that their boilers are out of warranty and typically tells them they need to buy 'Silver Plus' cover costing £119.99.
They are then told that they need to buy the product there and then, and are pressurised into giving their credit or debit card details using 'hard sell' techniques.
Pina Morrish, an 88-year-old widow from Cardiff, was recently contacted by the company. She said: "They called me one afternoon and frightened me into thinking I needed boiler cover.
"The man I spoke to seemed very nice and was well-spoken, but he was very insistent that I bought the cover there and then, and persuaded me to give him my debit card details."
Mrs Morrish, who is originally from Italy and settled in Britain after marrying a Welsh soldier in 1947, soon realised something wasn't right and phoned her daughter, retired deputy headteacher Christine De Souza, who immediately contacted her mother's bank to stop the payment and cancel her card.
Mrs De Souza, 59, who assists her mother with financial matters, said: "I discussed the possibility of getting boiler cover with my mother some time ago, but since she has it serviced on a regular basis, we agreed it wasn't necessary.
"My mother is still very independent for her age and makes her own decisions. It seemed very clear to me that this caller was using 'hard sell' techniques, because she is not easily manipulated, and was aware her boiler was in good working order following the recent service."
The following morning, Mrs De Souza phoned Heat Plan Utilities to try and establish exactly what has happened.
She asked how exactly they had obtained her mother's number, and was told that they got it through a survey she had completed. Mrs De Souza said it was highly unlikely her mother had filled out a survey, and was told: "If she can give card details, I'm sure she can complete a survey."
Mrs De Souza replied that she was sure she knew her own mother a lot better than they did. Angered by his attitude, she asked to be put through to a supervisor, but he initially refused to, claiming they were merely selling insurance.
Undeterred, Mrs De Souza insisted she be put through to a supervisor, and he eventually agreed to do so. After being kept on hold listening to music for an extended period, she hung up the phone. She has since reported the company to Trading Standards and the Citizens Advice Bureau, who were both sympathetic, but didn't believe any laws had been broken.
There are a number of near-identical stories about Heat Plan Utilities on internet forums that deal with issues relating to care of the elderly. Typically, the calls take place during daytime hours and the same price, £119.99 is quoted.
Michelle Mitchell, Charity Director at Age UK said: "Scams can take place on the doorstep; by phone, on the internet or through the post and the sad fact is that if something sounds too good to be true then it probably is. If you feel under pressure to commit, then just step away because any reputable company will allow you time to think an offer over.
"Anyone can be taken in by a scam so people shouldn't be embarrassed to report a crime. If you feel you are or have been a victim speak to the police, a family member or friend."
Matt Smith, of Heatplan Utilities, defended his company's sales techniques. He said: "We obtain our information from surveys, and if people are well enough to give their credit card details over the phone, they are well enough to complete surveys. Our sales techniques are perfectly legal."
Meanwhile Mrs Morrish considers herself to be one of the lucky ones. She said: "I was fortunate in that I realised I had been mis-sold the insurance very soon after the call, and there was enough time to stop the bank payment from going through.
"I'm sure there are plenty of vulnerable elderly people who weren't so lucky, and I'd urge those who look after older people to remind them not to give their card details over the phone, or to feel pressurised into buying products they don't need by telesales calls."


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The gripping untold story of the Brexit negotiations… from the other side. For two years, Belgian film-maker, Lode Desmet, has had exclusive access to the Brexit co ordinator of the European parliament, Guy Verhofstadt, and his close knit team. This revelatory fly-on-the-wall film captures the off-the-record conversations and arguments of the European negotiators as they devise their strategy for dealing with the British.
Part 1 watches as the Europeans' respect for a formidable negotiating opponent turns into frustration and incredulity as the British fail to present a united front. At moments funny and tragic, it ends with the debacle in December 2017 when Theresa May flies in to Brussels to finalise details of a deal and is publically humiliated by her coalition partner, Arlene Foster of the DUP, who refuses to support the deal.
Part 2 follows the rollercoaster events from December 2017 to the present day. Europe watches on incredulously as divisions in the British parliament and cabinet become more bitter and leave the talks paralysed. Eighteen months after the referendum, Britain still does not know what it wants and spends more time discussing internally than negotiating with Europe. Respect for Britain turns to irritation and finally ridicule.

subset: commoncrawl


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Fifty years ago today, August 9, 1963, Patrick Bouvier Kennedy died of hyaline membrane disease, a lung disorder, at Boston Children's Hospital.
Doctors and hospitals could do very little in those days for babies with this problem, which is caused by the formation of a glassy membrane on the air sacs of the lungs. Fortunately, highly effective treatments have since been developed. Few newborns die today of hyaline membrane disease in the developed world.
In an article published July 30, 2013, Lawrence K. Altman, a medical doctor and correspondent for the New York Times, wrote, "If Patrick were being born in August 2013, his odds of surviving would be better than 95 percent." If you'd like to read the Altman piece, click on this link:
Patrick was born on August 7 at the Otis Air Force Base hospital in Bourne, MA. His mother, Jacqueline Bouvier Kennedy, was vacationing on Cape Cod when she went into labor, five weeks before her due date. Doctors delivered the baby by Caesarean section.
The funeral Mass for Patrick was held the day after he died in the private chapel of the Commonwealth Avenue home of the Archbishop of Boston, Cardinal Richard Cushing. Only a few people were there.
The late Richard Reeves described what happened at the end of that Mass on page 553 of his superb book, "President Kennedy, Profile of Power," which came out in 1993:
"…Jacqueline Kennedy was still in the hospital on Cape Cod. Her husband was on his knees, seemingly unable to let go of the little white coffin in front of him. 'Come on, Jack, let's go,' Cushing said finally. 'God is good.' "
A little earlier in "President Kennedy," on page 539, Reeves recounts a meeting Kennedy held with his Secretary of State, Dean Rusk, regarding an upcoming presidential visit to Europe:
"As the European trip was being planned, the President had asked Rusk if he knew of a beautiful and secluded place in Italy for a private matter. Rusk did. He had been president of the Rockefeller Foundation, which owned Villa Serbelloni on Lake Como, once the grand vacation home of a Milanese merchant prince. Kennedy said he wanted the villa on the night of June 30 and he wanted it empty – no servants, no staff, no Secret Service. Powers and O'Donnell would be there to handle any problems, that was part of their jobs. But somebody didn't get the message. It soon became apparent that the resident director of Rockefeller programs at the villa and his wife, Mr. and Mrs. John Marshall, were intending to stay on the property, moving into guest quarters.
" 'Get them out of there,' " Kennedy said, and the State Department was on the way. The Marshalls left and soon afterward a lady of some note in Europe arrived. Rusk returned in the morning. 'How was it?' asked Rusk, who did not approve of some of Kennedy's habits.
" 'Wonderful,' Kennedy said. 'Absolutely wonderful.' "
In the 105 days he remained alive after his son's death, did Kennedy's conscience ever cause him to conjure a connection between the events of June 30 and August 7 through 9, 1963?


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The story so far for first year Planet X junior Jake SCOTT who has decided to challenge himself by cycling up in Elite races, this is what he has to say!
SHEFFIELD GP 1hr – 25th July 12
A skip and a jump across the Woodhead to Sheffield, after sorting my kit out I wondered to the little boys room and bumped into Dave (The Boss) and Big FrankI wasn't expecting that one.
Anyway restricted gears or not I was prepared to give it my best shot, the course was fast with tight corners, cobbles, long windy straights, and oh yes those professional riders.
I lasted 40 minutes with the main group trying as hard as I could but then got dropped back to a smaller group because the pace was so quick and relentless. I managed to finish on the front of the group I was in kicking off the front for the finish I was only glad that didn't get lapped, but I knew I,dbeen in a bike race.
BBM 90 miler – 29th July 12
Turning up to see Raleigh GAC, made a hard race even harder, the weather looked good but half way through the first lap the heavens soon opened, with the lads from Raleigh spotting the cross wind.
The first lap the race was soon split in to 2 groups which contained 6 Raleigh riders, me and 5 from other teams. After settling down we soon had a good 3 or 4 minute gap but with 6 Raleigh boys they weren't going to leave it for a group sprint.
So a 4 man group sneaked off up the road with 3 Raleigh riders included, trying to help get the group back, Isoon found myself lacking energy and when the other Raleigh riders put the hammer down I was shelled with 2 to go, riding a lap on my own and a lap with a group of 4 I ended up finishing 15th, a very hard race indeed.
CROSSTRAX70 miler – 5th August 12
Not much too tell really, a rolling course with a hard flat section on the other side of the course, with an Elite line up of again 6 Raleigh lads, 3 or 4 Motorpoint and a couple of Endura chaps including Ian Wilkinson.
The pace high from the start the group soon got smaller, and with a big group nipping away with a lap to go I was soon on the back foot, but we got the majority of that group back which meant I was still in for a good position, with a group of 10 up the road points were still available, so with the finish on a hill it was time for a big last effort, eventually I finished 15th beating a couple of the Raleigh lads, and also a couple of Motorpoint riders, job done a good days riding.
BELGIUM Weekend 11th August 12 -Interclub 112 Kilometres – 11/8/12
I was invited to ride in Belgium on a 6 man composite team in a UCI race which consisted of 12 laps with 21 teams totalling 150 riders.
The weather was extremely hot 28 degrees but with cross winds, the roads varied from rough to smooth and from narrow lanes to fast straight streets through the town centre and open country side, it was definitely a testing course.
There was a lightening pace from the off with a the lead riders opening up a 1 and a half minute lead, all the Brits played our part chasing down bringing riders across and creating gaps which resulted in 3 distinctive groups. After trying to get across to the front group I gave it up as a bad job and decided to stay where I was and finish, and due to our individual overall finish positions we took the 3rd place prize out of 21 Teams happy days.
2nd day Local Race Individual 96 Kilometre – 12/8/12
The local races are usually easier than inter clubs we were all looking forward too a bit of prize money, but when Garmin Slipstream Junior Development Team turned up, and a few hopefuls from the American national team, we soon realised it could be a bit of a challenge.
So sporting my best Planet X Guru kit I thought in for a Fenning in for a Deutsch Mark ! Just like day 1 the race set off at a furious pace, but half way through the race I started too realise that the Garmins boys weren't showing what we thought they would, so with a break up the road with 3 fellow Brits in it I eventually jumped across.
However with the style of the course we were brought back 3 laps later, so I dropped back in the bunch took a breather and formed a cunning plan for the last lap, I worked my way towards the front of the bunch and with about 400 metres to go gave my all.
I thought I had it in the bag but one of the Belgium riders knicked it on the line by half a wheel leaving me in 2nd place, but taking a few Euros pocket money eased the pain and 2nd out of 102 isnt bad, but I,m still looking for that first win !
21 August 2012


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Reggie And The Full Effect Announce 'No Country For Old Musicians'
Reggie And The Full Effect will release No Country For Old Musicians on November 19th with Pure Noise Records. The record will serve at the relaunch of Reggie And The Full Effect and you can read more about the project via Kickstarter here. You can pledge to the project and purchase a CD here and buy concert tickets for any upcoming tours here. Check out the album artwork and track listing after the jump. Please follow and like us:Read More


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Are your air filters ready for the upcoming season? As the temperature heats up, now is the time to start thinking about switching out your air filters. Regularly changing your air filter can improve the air quality within your home, as well as improve system efficiency. Helping the system perform more efficiently can even help you save money on your monthly energy bills and emergency repair costs. To get the most out of your AC, most professionals recommend changing your air filter every month. That's even more important during the summer months, when your AC is getting the most use.
Still wondering why this chore is so important? Here are a few benefits of replacing your air filter.
Longer lifespan
Most people assume a dirty air filter doesn't have any effect on their unit. In actuality, a dirty air filter is one of the most common reasons for needing repairs by your HVAC contractors in Colorado Springs, CO. The accumulated dirt prevents air from passing through, which will eventually cause it to overheat. As a result, the motor has to exert more and more energy to push the air through. You could be forced to replace your unit entirely if the problem goes ignored long enough. Replacing the filter regularly will prevent the buildup of dirt and help you get the most out of your HVAC.
Cut down on repairs
As previously mentioned, dirt accumulation from failing to change the air filter is one of the most common causes for breakdowns. The repairs can cost you hundreds or even thousands of dollars—not to mention the discomfort as you're left waiting in the heat for your HVAC contractors in Colorado Springs, CO. On the other hand, most air filters cost no more than $30, and many of them cost far less. It should be clear that opting to replace your air filter is the best option from a financial standpoint.
Reduce energy costs
Your air conditioner requires more energy to keep your home cool when the air filter is clogged. Your energy bill will increase drastically as more and more energy is needed for the unit to function. Changing the air filter can reduce your monthly energy costs by helping your AC perform as efficiently as possible. Most homes can cut their bill by approximately 10 percent just by making this simple change.
Improve air quality
A dirty air filter may be the cause for worsening allergy symptoms. When the air filter is dirty, the allergen-filled air will just circulate throughout the home instead of being filtered out. The lack of access to clean air can exacerbate asthma or allergies. Replacing the air filter once a month can help your family breathe easily again.
Changing your air filter can save you money by improving the efficiency of your air conditioner or HVAC system. You'll soon be happy to perform this simple chore once you see the decrease in your monthly energy bills and the reduced frequency of repair calls. Contact BullsEye Plumbing Heating & Air for more information about the importance of changing your dirty air filter.
Look no further than BullsEye Plumbing Heating & Air for your Air Conditioning needs in Colorado Springs and Denver. If you need a repair on an existing Air Conditioning unit in Colorado Springs or Denver, we've got you covered! If you need a new Air Conditioning unit all together we've got you covered for that as well! Click below to schedule your appointment and fix all your Air Conditioning needs.
Whether you need heating services, cooling services, plumbing services, an HVAC system evaluation, repair, or replacement, or utility excavation, you can call on us to do the job and get it right the first time.


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Micronations.wiki costs £160 per year to keep online.
Since we are unable to run advertisements, we ask that any users who are able to do so
make a contribution so that Microwiki may continue to survive and thrive. Thank you!
MicroWiki talk:Good articles
I will remove the Alaurentia nomination entry. It has been over a week now, and no one has voted either in support or in opposition.
I will try again in a month, in accordance with the rule. -the Dragon of Alaurentia, President of Alaurentia, 1:14, 17 May 2019 (UTC)


text: Our latest film SPRAY is now on sale for a limited time only. Visit www.BSProductions.us to get your copy for only $20. SPRAY makes a great gift for the holidays and we'll make sure all domestic orders placed before December 19 get to your door in time for X-mas! Order now, this deal won't last forever!


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26 Sep 2018
Record held: 1549-1647
Height: 151m (495ft)
St Mary's Church in Stralsund, northern Germany, became the world's tallest building in 1549, despite being shorter that its predecessor. Like Lincoln Cathedral, it lost its title in a storm. Its steeple tower was struck by lightning in 1647 and rebuilt as a dome. It now stands 104 metres high.
The 15 cities with the most skyscrapers - where does London rank?
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Co-created with input from key stakeholders, the Graduate Profile is a clear visualization of priority goals for teaching and learning that can be easily communicated to students, parents, faculty, and staff to align their collective efforts. Adoption of a Graduate Profile is a nationwide movement to address the shift necessary in education to prepare students for the jobs of the future.
How was ESUSD's graduate profile developed?
Last year, discussions, workshops and surveys were conducted with key stakeholders – teachers, administrators, parents, business and civic leaders – to develop the graduate profile for ESUSD. Feedback was obtained from business and civic leaders through the use of guiding questions such as:
- What skills and characteristics should high school graduates develop to ensure success in the workplace of the future?
- What skills and characteristics are most important in a graduate?
- What can we do as an educational organization to better prepare graduates?
ESUSD teachers and administrators then took the set of 21st century learning skills and applied the stakeholder feedback to develop a subset of skills/attributes and key performance indicators under each category, as outlined on the Graduate Profile Scorecard.
ESUSD is dedicated to helping students build the following new 21st century learning skills: empowered learner, digital citizen, knowledge constructor, innovative designer, computational thinker, creative communicator and global collaborator. In conjunction with the leading research regarding refocusing education's role in supporting students' preparation for the job market of the future, ESUSD used the International Society for Technology Education Standards to initiate the conversation for its new Graduate Profile.
The ESUSD Graduate Profile describes the expectations our community believes our graduates should possess in order to become the successful leaders of tomorrow. The districts that have already engaged in this nationwide initiative have discovered many ways to use the graduate profile as a means for transformative change.
Research tells us that when the kindergartners of today graduate in 2031, the world will be vastly different from anything previous generations experienced. ESUSD has embraced the changing face of education from a standardized system to a learner-centric environment that adapts to the needs and potential of each student.
Please visit our new Graduate Profile web page on the ESUSD website. The page includes additional information about the Graduate Profile, a one-page document outlining ESUSD Graduate Profile, a list of stakeholders and community members involved in the development conversation, and links to articles supporting the Graduate Profile philosophy.


text: Category: shankar May 30, 2011 shankar hot tamil movie photos shankar thamil movie photos , sankara tamil bgrade movies stills , shankar new photos , shankar tamil hot stills , shankar movie unseen stills , shankar movie new latest photos Share this:TweetEmailPrintShare on Tumblr October 29, 2010 enthiran story looted from a tamil story book jookiba / yookiba enthiran story copied from a tamil book jookiba or yookiba , it came in 96 .enthiran original story . read original source of enthiran story . read yookiba enthiran story book online.enthiran movie is heavily inspired from this story jookiba. click the image to enlarge the image. Share this:TweetEmailPrintShare on Tumblr


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Sara currently works as an International Operations Specialist at Achievers. She's the second Achiever's woman I'll be interviewing this year as part of the Achievers Women's Network (AWN) efforts to highlight female leaders in different stages of their career throughout the organization. Sara has this amazingly strong, positive, and open spirit so I immediately felt connected to her when we started chatting. Her journey overcoming the challenges of immigration and coming out triumphant really resonated with me – given it's similarity to mine. I'm so honoured to be sharing her journey from the world of journalism in Spain, to the world of tech in Canada – and everything in between!
Tag: Toronto
Debbie Lillitos
Debbie currently works as the Vice President of Professional Services at Achievers. She's the first of Achiever's women I'll be interviewing this year as part of the Achievers Women's Network (AWN) efforts to highlight female leaders in different stages of their career throughout the organization. From the moment I met her, Debbie's energy, warmth, and her openness to sharing her experiences really stood out to me. I was intrigued to learn more about her journey from a management consultant to a VP of a software company, some of the challenges and learnings she's gone through, and her ideas around inclusiveness and equality at work.
Breanna Hughes
Breanna currently works as a Product Manager at Universe. I met her when I started working at Wattpad last year, and she stood out to me as a smart, independent, no-nonsense woman who was not afraid to speak her mind. Her candor is seen as refreshing to some, and intimidating to others – or even both in some cases. Either way, she's a force to be reckoned with – striving to challenge stereotypes both in tech and beyond. She was one of the first people who came to mind when I started this blog, and I'm really glad that I had the opportunity to chat with her a few weeks ago. We talked about her background and journey into Product, the experiences that have shaped and molded who she is today, and her various contributions to the fight for equality – a movement very close to her heart. Continue reading "Breanna Hughes"
Kaitlin Smith
Kaitlin currently works as a Producer at Uken Games. I was introduced to her by our mutual friend, Kelly, who thought she would be a perfect fit for the blog! Within less than 10 minutes of meeting her, I felt a connection to her as we shared laughs throughout her photo shoot. I was super excited to learn more about what exactly a Producer does, her journey from engineering to her current role, and her thoughts on how we can continue to push for gender parity in STEM. Continue reading "Kaitlin Smith"


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The evolution and progress of standard procedures for intraoperative nerve monitoring
The recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerves (EBSLN) are at risk of injury during all thyroid and parathyroid surgeries by virtue of their close proximity to the operative field and injury to these nerves can result in significant patient morbidity secondary to the voice, swallowing and breathing issues that nerve dysfunction triggers. During neck endocrine surgeries, rates of nerve injury have traditionally been reported as low (3–5%). However, more recent series suggest that these past reports have significantly underestimated the true incidence, citing rates closer to 10%. Similarly, although actual incidence of EBSLN injury remain unknown, it may approach 58% (1,2). These inconsistencies in reported injury rates likely relate to many factors including a lack of standardization of pre and post-operative laryngeal examination practices, the often subtle and variable nature of nerve palsy symptoms, and reporting biases from large thyroid centers where complication rates are low. Clinical implications of unilateral RLN injury revolve around breathing, phonation, and swallowing with severity ranging from mild impairment to severe. Conversely, bilateral RLN injury can necessitate the placement of a tracheostomy by causing a grossly narrowed, immobile larynx and significant respiratory distress. Clinical symptoms of EBSLN injury are variable, often may be overlooked, but can be significant, especially to professional voice-users. The symptoms include vocal fatigue and decreased pitch and inability to project voice. The laryngoscopy findings associated with EBSLN injury include posterior glottic rotation toward the paretic side, bowing of the vocal fold on the weak side and inferior displacement of the affected cord. Notably, these findings can be subtle and can easily go unnoticed.
Techniques to identify and monitor the laryngeal nerves during neck endocrine procedures have been developed over the past 50 years with the aim of minimizing postoperative nerve dysfunction and thus lowering patient morbidity. Many techniques have been proposed, from simple nerve identification to intermittent and, now, continuous nerve monitoring. Specialized committees have been formed and guidelines have been published to encourage standardization of monitoring techniques. This has helped in uniform collection of monitoring data across different populations of patients and surgeons, which along with technical advances in neuromonitoring techniques and better understanding of neurophysiology of the larynx have been instrumental in continued evolution of monitoring strategies and management algorithms. This article discusses the evolution of these monitoring techniques over the past five decades and highlights the current international recommendations for neural monitoring in neck endocrine surgery. Future directions in nerve monitoring will also be discussed.
Evolution of intraoperative nerve monitoring (IONM)
One of the earliest reports of electrical RLN and EBSLN identification, stimulation and response evaluation was in 1966 in the Annals of Surgery. This study used a canine model intubated with an endotracheal tube (ET) with a balloon placed within the larynx and connected to a pressure-recording system. Results indicated that the pressure changes from an intralaryngeal balloon consistently showed changes upon RLN electrical stimulation and, for the first time, provided a method for electrical identification of the RLN. Similar changes were noted for the SLN. The same group translated this research to the human population during thyroid surgeries, showing that endolaryngeal balloon pressure recording could indicate when the RLN and SLN were stimulated (3). In 1970, Riddell published a 23-year series spanning from 1946 to 1969, reporting on RLN identification using laryngeal palpation with simulation of the RLN as an additional safety measure for nerve protection during thyroid surgery (4). In 1986, palpation of the posterior cricoarytenoid muscle with nerve stimulation of 0.5–2.0 mA was presented as a simple and safe technique for RLN identification and assessment during thyroid surgeries, in addition to a thorough knowledge of cervical anatomy (5).
Over the past thirty years, different IONM techniques have been proposed including laryngeal palpation (Figure 1), glottic pressure monitoring, glottic observation, intralaryngeal hookwire electrodes, ET based electrodes and post cricoid surface electrodes. Of these, ET based surface electrodes (Figure 2) are currently the most popular for monitoring of the RLN in thyroid surgery and have several advantages over other methods including ease of set up, non-invasive nature and large EMG potentials recordable with such electrodes. However as with any neurophysiological monitoring category, whether intracranial, spinal or peripheral, standardization of IONM technique is necessary to ensure that results generated are repeatable, reliable and clinically meaningful. Studies investigating the utility of IONM compared to direct nerve visualization alone have varied greatly with regards to inclusion criteria, laryngeal examination practices, type of monitoring applied and reported results. Most studies have used ET based surface electrodes to record electromyographic potentials elicited by vocal fold contraction in response to intermittent direct nerve stimulation. More recently, there have been a number of series reporting methods of continuous intraoperative nerve monitoring (CIONM) which has the advantage over intermittent stimulation techniques of assessing real-time nerve integrity and thus better preventing impending nerve injury. Data is lacking as to whether CIONM will ultimately reduce temporary and/or permanent RLN injury rates however the concept, by virtue of its potential preventative benefits, is appealing.
It is important to remember that a key element in the anesthetic technique with IONM is the avoidance of muscle relaxants or the use of muscle relaxants with a very short half-life for endotracheal intubation. In general, to date the research and documentation involving the anesthetic techniques for IONM are limited. As IONM techniques and applications continue to evolve, the need for a collaborative environment between the surgeon and anesthesia services leading to optimal IONM for better surgical outcomes is increasing. Macias et al have published an interdisciplinary collaborative protocol for monitored neck surgery based on the evidence and clinical experience of over 3,000 cases (6).
Uptake of IONM worldwide
There has been increasing interest in IONM over the past decade as outcome measures assume greater importance in patient care algorithms and as more practitioners recognize that macroscopic nerve identification and preservation does not necessarily equate to functional neural integrity (7-13). In 2006, the American Association of Endocrine Surgeons (AAES) evaluated attitudes about neuromonitoring, usage patterns and predictors of its use via email surveys. Non users of IONM tended to be older (P=0.023) with a lower case volume (P=0.003), less familiarity with the technology (P<0.001), and less access to the equipment (P<0.001) (8). However, despite these findings, the percentage of surgeons in the United States who always use nerve monitoring continues to increase particularly amongst young surgeons, academic surgeons and those in high volume centers. In Germany, IONM is standard of care and, according to a national survey in 2010, 90% of surgical departments in Germany are equipped with nerve monitors with RLN monitoring used in 93% of thyroidectomies (10,14). In the United Kingdom, a minority of members of the British Association of Endocrine and Thyroid Surgeons (BAETS) use IONM, however this proportion is gradually increasing (11). In a 2005 study from the UK, patient age did not impact on the use of IONM however type of disease present (malignant versus benign) and timing of surgery (revision versus primary procedures) were both significantly correlated with IONM usage (P<0.00001) (12). In Denmark, an IONM usage rate of 77% has been reported from a registry of surgical results in 2007 (13) and similarly, in France, IONM use increased from 6,200 in 2008 to 10,000 in 2010. Reports out of Italy, Poland, Spain and China have reported similar utilization trends. A survey from Italy identified that the main motivations for IONM use included medico-legal reasons (30%), RLN confirmation (20%), RLN identification (20%), prognosis (10%) difficult cases (10%), decreased surgical time (5%) and education (5%). High volume and academic centers reported use more consistent with published guidelines of IONM (15). The recent world-wide standards and recommendations published in guidelines by various organizations are described in the "Current Standards for IONM in thyroid and parathyroid surgeries section" below.
IONM in the reduction of RLN injury
The end-points of most published series looking at IONM in neck endocrine surgeries are transient and permanent RLN injury. However, the ability of many trials to demonstrate a clear benefit of IONM over no monitoring is limited by heterogeneity as well as lack of adequate power in study design. This heterogeneity is due to many factors including variability in pre- and post-operative laryngeal examination practices, utilization of different formats of IONM (e.g., invasive versus noninvasive devices, audio versus audio plus EMG documentation), sample size limitations, histologic nature of the pathology, type and extent of the surgical procedure, and surgeon's expertise. Dralle et al. have shown that it would be very difficult to have an adequately powered study to differentiate between visual identification alone and IONM, as such a study would require 9 million nerves at risk (NAR) in benign goiter patients and 40,000 NAR in thyroid cancer patients per arm to detect statistical significance (16). One of the larger studies performed to assess the value of IONM in neck endocrine procedures was by Barczyński et al. (17). In over 850 patients undergoing revision thyroidectomy, there was a statistically significant reduction in transient (2.6% versus 6.3%) and permanent (1.4% versus 2.4%) paralysis rates between patient receiving IONM and those without IONM. Another study by Barczyński et al. compared the outcomes of 1,000 patients with IONM versus 1,000 patients without IONM (18). They found that there was a lesser prevalence of transient nerve damage in the IONM group among high-risk patients. Additionally, there was a difference between low-risk and high-risk patients which did not reach statistical significance. Overall conclusions from this prospective study were that IONM, compared to visualization alone, reduces the incidence of transient, but not permanent, nerve injury. Thomusch et al. studied over 5,000 procedures and concluded that IONM of the RLN in thyroid surgery significantly (P<0.05) lowers rates of transient and permanent RLN palsy compared to visual RLN identification alone (19). Yet other studies have demonstrated that IONM can reduce operative time and related costs but virtue of less time taken to identify the RLN.
A meta-analysis by Zheng et al. analyzed 5 prospective randomized studies and 12 comparative non-randomized studies (20). The global sample was >36,000 NAR. Transient neural damage was significantly reduced in the IONM group (2.56%) compared with 2.71% without IONM however permanent events showed no statistical significance. Pisanu et al. analyzed 3 prospective studies and 17 comparative non-randomized trials with a global sample of >35,500 NAR and reported similar RLN paralysis rates between with-IONM and without-IONM groups (21). Sanabria et al. analyzed prospective trials only with a global sample of >3,000 NAR and noted no statistically reduced rates of temporary or permanent RLN paralysis with IONM, although there were trends towards such significance in both groups (22).
Important applications of IONM
The intraoperative assessment of RLN function with IONM during thyroid surgery is uniquely advantageous for many reasons, some of which are listed below as a lead-in to the subsequent discussion on current guidelines and standards for IONM in thyroid and parathyroid surgeries.
- Early nerve identification and mapping. Particularly during complicated thyroid operations, early RLN identification can help avoid inadvertent nerve injury. Multiple studies have shown that IONM improves visual nerve identification rates by allowing for the nerve path to be mapped using probe stimulation at 2 mA well before visual identification is possible. Once the nerve is visually identified, stimulation at a current of 1 mA allows for mapping of the nerve.
- To identify anatomical variations such as extralaryngeal branches, specifically the motor branches, as well as non-RLN (23). It also identifies distortions in the nerve position caused by the primary thyroid disease process (e.g., substernal extension of a large thyroid goiter).
- Assistance in optimizing tissue removal during total thyroidectomy by facilitating dissection of tissues in the region of the ligament of Berry.
- Intraoperative detection of impending neuropraxic neural injury likely allowing alteration of causative surgical maneuvers. It is important to realize that IONM is more useful in stretch or compression injury than in transactional nerve injury.
- Prognostication of postoperative neural function, this assumes particular importance in bilateral surgeries, for prevention of bilateral vocal fold paralysis (BVFP). IONM can prevent bilateral RLN palsy associated with total thyroidectomy by alerting the surgeon to consider a staged procedure when ipsilateral LOS occurs. Standardized LOS troubleshooting algorithms have been developed to assist that the surgeon using IONM in identifying the true LOS and determining optimal course for any remaining parts of the surgical procedure.
- Improved rates of identification of superior laryngeal nerve.
- Educational and medicolegal reasons.
- For low volume surgeons, RLN monitoring may significantly decrease the frequency of permanent RLN paralysis (24).
Current standards for IONM in thyroid and parathyroid surgeries
There is increasing organizational support for IONM in neck endocrine surgeries, catalyzed at least in part by the introduction of non-invasive monitoring devices, publication of guidelines defining standards for RLN/EBSLN monitoring and of randomized prospective trials as well as by establishment of structured training courses. The American Academy of Otolaryngology and Head and Neck Surgery (AAOHNS) guidelines on voice preservation during thyroid surgery state that IONM is an option for patients undergoing thyroid surgery in order to (I) reduce RLN identification time, (II) decrease temporary VCP rates, and (III) avoid bilateral VCP (through prognostication of postoperative vocal cord function). These guidelines suggest significant utility of IONM in cases of (I) bilateral thyroid surgery, (II) revision thyroid surgery, and (III) surgery in the setting of an existing RLN paralysis (25). Similarly, guideline statements from the American Head and Neck Society (AHNS) on recurrent thyroid carcinoma (26), central neck dissection (27), and invasive thyroid carcinoma (28) concur that IONM is a valuable tool to assist with nerve identification, maximizing nerve functional integrity and prognostication of postoperative laryngeal function. The American Thyroid Association (ATA) has made mention of IONM within a number of consensus statements and guidelines. Recommendation 42 of the ATA 2015 Guidelines for Thyroid Nodules and Well Differentiated Thyroid Cancer (29) state that visual identification of the RLN during dissection is required in all cases and that intraoperative neural stimulation (with or without monitoring) may be considered to facilitate nerve identification and to confirm neural function". In addition, they note that training and observation of existing monitoring standards are important to provide optimal benefit from IONM given the complexity of monitoring systems. Two additional ATA Surgical Affairs Committee consensus statements (on outpatient thyroid surgery and on optimal surgical management of goiters) note that neural monitoring can be helpful in confirming intact neural function at the end of surgery, which may impact on discharge planning (30,31). Both the German Association of Endocrine Surgery and the International Neuromonitoring study group (INMSG) recommend neural monitoring in all cases of thyroid and parathyroid surgery.
The International Neural Monitoring Study Group (INMSG) was founded in 2006 to serve the emerging field of neurophysiologic monitoring of laryngeal nerves in neck endocrine surgery. It is an international multidisciplinary collaboration with experts in the field of neck endocrine surgery, laryngology, electromyography, anesthesiology, and neurophysiology. The goals of this collaborative group are to improve the quality of IONM, reduce inappropriate variations in IONM technique, adhere to strict standardization, foster the growth and stature of neurophysiological monitoring, encourage research, improve and update guidelines, implement IONM courses, develop quality standards for practice and training, define unequivocal references of RLN neurophysiology and pathology, refine EBSLN monitoring and evaluate new developing technology such as CIONM. They have published guidelines on RLN and EBSLN IONM standards for monitored thyroid and parathyroid surgery (32,33). The standards described in these guidelines brought uniformity in application of IONM during endocrine neck surgery. Since the publication of these guidelines, several papers documenting normative electromyography (EMG) data of the vagus nerve, RLN and EBSLN have been published (34-36).
To recognize abnormal EMG responses and to meaningfully interpret the EMG responses recorded by IONM, establishing normal range of EMG responses for Vagus nerve, RLN and EBSLN is important. Sritharan et al. (35) have delineated normative waveform morphology, mean latency and mean amplitude of the left and right vagus nerve, pooled RLN and pooled EBSLN (Figure 3). Caragacianu et al. have proposed an intraoperative EMG criteria, which when present imply normal vocal cord function postoperatively (37).
More recently INMSG has written the soon to be published, a two-part consensus guideline discussing nerve monitoring for neck endocrine procedures. These documents contain an extensive discussion of staging bilateral thyroid surgery with monitoring loss of signal (LOS) (Part I) and of optimal RLN monitoring for invasive thyroid cancer (Part II). These are explicitly detailed documents and represent the most expansive guideline statements to date with evidence based literature reviews and technical discussions. They greatly help with the standardization of current techniques and clarify potential pitfalls of IONM in thyroid and parathyroid surgeries.
Part I of the INMSG guidelines discusses the use of IONM in bilateral thyroid surgery. BVFP results in tracheostomy in approximately 30% of patients. IONM provides a way of determining whether a nerve exhibits a LOS, thus potentially preventing bilateral BVFP by allowing the surgical procedure to be staged. The definition of LOS was proposed by the INMSG in 2011 as an EMG signal with amplitude of 100 µV or less. For this criteria to be used, initial EMG amplitude should be 500 µV or greater. Most LOS injuries occur due to traction, especially around the ligament of Berry. However, few of these injuries will be visually evident intraoperatively. Although recently there has been a movement towards unilateral thyroid surgery in low risk cancers up to 4 cm, rates of total thyroidectomy continue to increase in the US and around the world, and all surgeons—regardless of caseload volume—have increased complications with total as compared to hemi thyroidectomy. Interestingly, contralateral cord paralysis after ipsilateral LOS appears to higher than rates where no ipsilateral LOS occurs, likely due to patient and surgeon related factors. Thus, when LOS is incorporated into the surgical strategy by staging a planned bilateral thyroidectomy, rates of bilateral VCP and tracheotomy can be dramatically reduced (Figure 4). The cost effectiveness of neural monitoring and LOS/staged thyroidectomy has also been shown to be favorable. The Part I document also introduces a 'yellow-red-black' type model to represent the various stages of possible RLN injury. EMG-Yellow reflects impending neuropraxia with amplitude decrease of 50% or more and latency increase of 10% or more, the so-called 'combined event'. These changes are often reversible with alteration of the surgical maneuver. EMG-Red reflects evolving neuropraxia with a further increase in the risk of VCP from the 'yellow' stage that occurs as the EMG amplitude drops to 100 µV or less. The Final EMG stage is the F-EMG-Black whereby the final EMG is considered as recovery EMG if both an absolute value of 250 µV along with recovery to >50% of baseline amplitude are present. Laryngeal twitch response to nerve stimulation may also be useful to support final LOS.
Part II of the INMSG guidelines discusses optimal RLN monitoring for invasive thyroid cancer. The RLN is one of the most frequent sites of invasion for locally aggressive thyroid cancer. RLN dysfunction from carcinoma invasion often occurs insidiously and, preoperatively, may present with voice and/or aspiration related issues or may be asymptomatic. Thus, to identify possible RLN paralysis pre-operatively, laryngeal examination should be performed on all patients with (I) with preoperative voice abnormality (II) a past history of surgery that may have endangered the vagus or RLN or (III) all patients with potentially invasive primary thyroid disease or significant central neck nodal disease. Cross sectional imaging can further define the potential degree of nerve involvement when VCP is detected on laryngoscopy preoperatively. Different types of RLN invasion are possible including perineural invasion involving only the epineurium (shaving of tumor may be possible in these cases), and perineural invasion with additional invasion into perineurium and endoneurium (nerve resection may be indicated in these cases depending on additional factors as detailed in these guidelines). EMG information obtained intraoperatively can help guide decision making in the invaded nerve and assist in determining when nerve preservation versus sacrifice is indicated. For nerves with preservation of some glottic function or proximal RLN EMG activity, consideration should be made to preserving the nerve whenever possible.
Although intermittent IONM is extremely helpful, it can only provide intermittent RLN evaluation, allowing the nerve to be at risk of injury in between the stimulus. Hence, a new format of IONM that uses an implanted vagal electrode (Figure 5) to constantly provide a real time intraoperative EMG data of vagus nerve and RLN has evolved, it is termed continuous IONM (CIONM) (38-40). The adverse EMG changes detected by CIONM can indicate an impending neural injury and hence allow the surgeons to perform a corrective action like stopping/reversing underlying maneuvers that may have caused the adverse EMG changes, thus may be able to avoid a permanent injury. Phelan et al. analyzed EMG adverse events and have coupled amplitude decline and latency incline to identify mild combined events (mCE) and severe combined events (sCE). They defined mild combined event (mCE) as concordant amplitude decrease of 50–70% and a latency increase of 5–10% and sCE as concordant amplitude decrease of >70% and a latency increase of >10%. The study noted that mCE was not related to postoperative VCP, whereas the sCE could evolve into frank LOS, which were much less reversible and could lead to postoperative VCP.
Current standards for EBSLN monitoring
Evolution of EBSLN monitoring deserves special mention as it has been a much more recent addition to the IONM strategies. True rates of EBSLN injury after neck endocrine procedures are unknown but may approach 50% in some series. In part, this is because objective examination findings of such injury are often difficult to discern, even with direct laryngeal visualization. Voice changes after injury to the EBSLN can range in severity from mild to severe and causes altered fundamental frequency of the voice, difficulty producing high frequency sounds, and reduced vocal projection. However, due to the paucity of examination findings and lack of changes in vocal fold mobility, these changes are often overlooked and patients are reassured and discharged from follow up without further voice evaluation. EMG of the cricothyroid muscle (CTM) is the gold standard examination for diagnosis of EBSLN injury. Multiple classification schemes have been proposed to aid in EBSLN identification during thyroidectomy procedures, including the Cernea, Kierner, Friedman and Selvan EBSLN Classification Schemes (41-43).
Until recently, there were few reports in the literature describing how to identify and preserve the EBSLN during superior pole dissection. Most surgeons tend to avoid rather than routinely expose the EBSLN during thyroidectomy and reports on methods of EBSLN preservation in the literature have thus varied from visualization alone to electrical stimulation (44-48), although most surgeons tend to avoid rather than routinely expose and identify the EBSLN during thyroidectomy. In 2013, to improve the practice of neural monitoring of the EBSLN during thyroidectomy and parathyroidectomy, the INMSG published a guideline statement on EBSLN monitoring during neck endocrine surgery which introduced standardized procedures for EBSLN identification and stimulation (33).
As compared to IONM of the RLN, EBSLN monitoring is based on two distinct outcome measures, namely (I) evaluation of the cricothyroid twitch response (present in all patients); and (II) EMG glottic response of vocal cord depolarization identified on surface ET electrodes. This is present in 70–100% of patients depending on type of ET used, notably, the Trivantage tube (Figure 6) has higher sensitivity (49). Meticulous dissection of the superior thyroid pole is essential to ensure the EBSLN is not entrapped within branches of the superior vascular pedicle prior to vessel ligation and division. Approximately 20% of EBSLNs may not be able to be visually identified due to a subfascial/intramuscular course within the inferior constrictor muscle (44) however the INMSG guidelines recommend that attempts to directly visualize the EBSLN should be made in all cases. The cricothyroid twitch technique for EBSLN IONM is based on the following premises:
- The EBSLN needs to be stimulated as clearly presents (through CTM visual twitch assessment or endotracheal glottic waveform if observable) cranially and medially to the evolving superior pole pedicle (true positive stimulation);
- Stimulation of the pedicle that is to be divided is stimulated as negative for EBSLN (i.e., no CTM visual twitch or endotracheal glottic waveform) (true negative for absence of neural tissue in the pedicle provided that a true positive stimulation is initially obtained).
The Stimulation-Glottic EMG technique tor EBSLN IONM uses ET electrodes to measures the glottic depolarization resulting from ipsilateral EBSLN stimulation. This is thought to occur due to the human communicating nerve which is an extension of the EBSLN that innervates the anterior half of the ipsilateral vocal fold, described in up to 85% of anatomical dissection studies (50). Equipment-related measurement issues may explain why an identifiable glottic waveform is present in only 70–80% of patients using standard EMG tubes. False positive stimulation of the EBSLN occurs when a positive CTM waveform is obtained due to a nonneural shunt stimulation and may occur when 2 mA stimulation currents are utilized during nerve mapping. False positive results can be minimized by reducing stimulation current to 1mA following nerve identification and observing for a positive CTM twitch response. Liddy et al. (51) have studied correlation of diverse EMG response with presence or absence of visual and palpable muscle activation to document target muscles (those with concomitant muscular contraction) and non-target muscles (those with no concomitant muscular contraction) for RLN and EBSLN (Figure 7A,B). They noted that recording low-amplitude EMG waveform in non-target muscles when a nerve is stimulated can be explained by understanding the far-field artifactual waveforms concept. False negative results occur when the EBSN is misidentified for a nonneural structure, resulting in no CTM twitch (and no EMG response) following EBSLN stimulation, and may result from equipment related recording issues, blood or fascial covering over the nerve, insufficient stimulation current, neuromuscular blockade, and transient EBSLN neuropraxia.
There has been much recent progress in the evolution standard procedures for IONM during thyroid and parathyroid surgeries in line with the recognition that neural visual integrity does not equate to functional viability and with an increasing focus on optimizing outcomes in neck endocrine surgical procedures. Standardization and organizational support have been instrumental in promoting the use of IONM and in increasing the number of publications that report intraoperative EMG data with their meaningful clinical interpretations. These trends are likely to continue and, as evolution of the equipment for neuromonitoring continues and our understanding of laryngeal neuroanatomy expands, the options for IONM of the RLN and EBSLN will continue to advance.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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Cite this article as: Sinclair CF, Kamani D, Randolph GW. The evolution and progress of standard procedures for intraoperative nerve monitoring. Ann Thyroid 2019;4:1.


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Perspectives Newsletter March 2018
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Quickfire Challenge: The cheftestants go to Le Bernardin where they meet Justo Thomas, who's like the Jedi fish butcher. The cheftestants have to portion one cod and one fluke into as high-quality portions as they can in ten minutes. Fabio, Carla, Tiffany and Antonia end up on the bottom. It's particularly embarrassing for Tiffany, who is executive chef at a seafood restaurant. The top four are Blais, Mike, Dale and Marcel. They move on to the next round, where they have 45 minutes to make a dish using the discarded fish scraps, and the winner gets immunity. Dale wins immunity, though all of the dishes earn some praise from guest judge Bourdain.
Elimination Challenge: Restaurant Wars, guest judged by Ludo Lefebvre, one of my least favorite Masters contestants, because he is crazy. The twist this time is that it's a "pop-up" restaurant, meaning they aren't taking over an existing space. It's a one-night-only restaurant. Dale is one captain, due to his Quickfire win, and he chooses Marcel to be the other captain, so that they won't end up on the same team. The teams are Marcel, Angelo, Mike, Antonia and Tiffany versus Dale, Blais, Tre, Fabio and Carla. Weirdly, Carla is picked last. Dudes, she won the last challenge! And also, the diners get to vote on who is the winning team, so all those who say they cook for the diners and not the judges should be happy.
So Dale's team calls their restaurant Bodega. Fabio does front of house and Dale is the expediter. Here is their menu:
Appetizer by Dale: bag of potato chips with fried herbs and sea salt
1st course by Blais: raw tuna belly and fried chicken skin with chilies and lime. It's served in a can like tuna fish.
1st course by Dale: bacon, egg and cheese with homemade focaccia
2nd course by Blais: chicken-fried codfish and Brussels kraut
2nd course by Tre: pork shoulder, grits with cheddar cheese, Corona and lime sauce
Dessert course by Fabio: amaretto cake with candied lemon peel and cappuccino mousse
Dessert course by Carla: blueberry pie with dry milk ice cream
Marcel's restaurant is called Etch. Tiffany does front of house, which is not really her first choice. But she doesn't know how to run it, and the judges note that Fabio actually directs the servers while Tiffany just schmoozes. Antonia expedites, but there's a lot of bickering in the kitchen, mostly centered around Marcel. Here is the menu:
1st course by Tiffany: frisee and shaved asparagus salad with egg and chorizo
1st course by Angelo: crudo of fluke, grapes, pink peppercorns and lemon zest
2nd course by Marcel: roasted monkfish with kalamata olives, peperonata and parsley
2nd course by Mike: braised pork belly with octopus and cannellini beans
3rd course by Antonia: ricotta gnudi, braised oxtail ragout, arugula and lemon zest
3rd course by Mike and Angelo: slow-cooked lamb chop, cauliflower puree, turmeric, and honey
Dessert course by Marcel: duo of peaches (unripened peach and sweet peach with coconut foam and powder)
To the surprise of no one, Etch is the losing restaurant. The judges have critiques for all of the chefs, but it seems like Marcel takes the brunt of it. No one wants to throw Marcel under the bus, and they try to present a united front, but then Tiffany lets slip that her front of house suffered because the line was arguing, and then it ALLLLLL happens, where lots of fingers are pointed in varying directions, but mostly at Marcel.
Meanwhile, Team Bodega wins by a landslide. Blais earns praise from the judges and his teammates for elevating everyone else's food, and Fabio's front of house was top-notch. The winner is Blais. Finally, he wins one! And the praise of his teammates gives me a little confidence in his skills going forward. I was starting to wonder if it was like the Emperor's New Clothes.
And on the losing team, the judges decide to send Marcel home. Yay! But also, boo, because now who will I root against? I kind of like everyone who is left. Even weird old Angelo.
The morning after Jamie and Tiffani were eliminated (yay and boo respectively), Carla wakes up and is happy that she won the Elimination Challenge, but sad to see her friends leave. But she's also really proud to be one of the three remaining female chefs. This season did seem to be trending heavily female (in that it was about half and half until last week), and I was wondering when they were going to get around to mentioning it. Blais interviews that he's looking forward to an individual challenge, because in the group challenges, he's ended up on the bottom, and he doesn't want to be eliminated cooking anything but his own food. I think that's fair. I understand the need for group challenges, but I would be pissed if I got steamrolled or bullied into cooking something I didn't believe in, and then got eliminated. So since they showed Richard saying that, we'll definitely see an individual challenge this week, right? I might believe that if they hadn't made clear in the preview that it was Restaurant Wars.
There's a funny bit where Antonia says that neither Carla nor Tiffany would move into her room, because they don't want to become victims of the Black Hammer. It seems that Antonia is a bit of a bad luck charm, in that people who team up with her end up eliminated. This started in Antonia's original season and has continued in All-Stars. Will her streak continue this week?
The cheftestants report to Le Bernardin, Eric Ripert's famous restaurant. Anthony Bourdain greets them instead of Padma, and explains that, in his newest book, he profiled a dude named Justo Thomas, who works in the kitchen of Ripert's restaurant. He comes in every morning at seven, and by noon, he has butchered somewhere between 700 and 1000 pounds of fish. Holy crap. That's a lot of fish. That's half a ton of fish! One dude! In five hours! Also, he must reek when he leaves work. Wouldn't you hate to ride on the subway next to him? Bourdain explains that when Justo goes on vacation, it takes three people to do his job. That's job security, man. I hope he earns what three people would normally earn, too. If not, he could screen this episode to make his point.
The cheftestants head downstairs to meet the legendary fish butcher of Manhattan. Justo explains that his three tenets are saving fish, quality, and equal portions. Well, that's not a parallel construction. If I were grading Justo's essay, I would take points off. But then again, it doesn't seem that English is Justo's first language, so I might give him partial credit and just write a note in the margin. Anyway, Justo is a man of action, not words, so he shows off his skills. You can see when he discards the skin, head, and tail of the first fish, it's picked clean. And neat! Like you could stuff it with something and it would still look like a fish, not just like a mess of scales. The cheftestants are understandably impressed when Justo butchers two fish in eight minutes, and ends up with beautiful and equal portions, with none of the flesh wasted.
Bourdain introduces the Quickfire Challenge: they must butcher one cod and one fluke into portions good enough to serve at Le Bernardin, and they will have ten minutes, two more than Justo needed. Oh, how generous. Tiffany interviews that she's an executive chef at a seafood restaurant, so she knows how to cut fish, but she's usually not being timed or judged for quality. Marcel, because he's an asshole, is wearing a bandanna tied around his head Samurai-style. I'm not even going to go on about it, because he just wants the attention. He also tells a dumb story about how he had an allergic reaction the first time he butchered a fish, but he powered through. I'm willing to bet real money that the whole thing never happened, or maybe he got one hive, or whatever. Again, attention. Let's not give in to it.
Mike notices that Carla's struggling with the task. Fabio cuts his thumbnail, but decides to power through, and "take it like a man." Or like a Carla. I'm just saying. Also, he's bleeding all over the fish. I hope he gets points off.


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Auto enrolment: hold your nerve for the next increase03 April 2019
On 6th April, the rules around auto enrolment contributions to workplace pensions will change for the second time in a year. Last April, total contributions increased from 2% to 5%, with the amount paid in by an employee potentially trebling from 1% to 3% as under the new rules, employers only had to pay in 2%. Now, the total is set to rise again to 8%, with only 3% required from the employer. While many employers will pay in more than this, there is still a good chance that an employee's contributions will rise to 5% - a huge jump from the 1% of two years ago.
With some people potentially baulking at the idea of seeing less cash in their pocket each month, Andy James, head of retirement planning at Tilney, looks at the pros and cons of opting out of a scheme.
"From this month's payday, those in an auto enrolment workplace pension scheme will notice the contributions increase fairly significantly. This may feel like quite a pinch and it is understandable that people do not want to lose more of their disposable income each month. Some employees will already be paying more than the minimum contribution so will not notice this hike so severely. But for those who don't feel like they can afford it, opting out of their scheme altogether may seem like the only option.
"If people do choose to opt out of their auto-enrolled pension scheme, they need to seriously think about how this may affect their retirement. The money you save earliest in your career is the money that works hardest for you throughout your life, until retirement. Choosing not to contribute any more to your pension means you will be starting from a much smaller pension base when you retire and there is a good chance you will not have enough to fund the lifestyle you want.
"There are obviously other vehicles people can use to save tax efficiently for retirement, and they may choose to put 2% into an ISA or if they are under 40 a Lifetime ISA every month if that is all they can afford. While it is obviously a good thing to still be saving and a Lifetime ISA would attract a 25% government bonus on top of their contributions, they will be missing out on employer contributions and potentially tax relief too. So only saving 2% a month to try and save that extra 3% is actually a completely false economy as you will be missing out on an additional 3% contribution from your employer, so turning down free money.
"For those who are really struggling, it is always worth speaking to your employer. If an employer agrees to pay more than 3%, the individual's contributions will decrease accordingly. The government is not actually going to want a generation with no pension as that is very bad news for the economy in the long run. They may have underestimated how this would affect workers, or they may be relying on people's apathy where they just 'can't be bothered' to change their scheme.
"The most important thing for people to do is to get their finances in order and truly understand how these increases will affect them going forward. With the current unstable political landscape, none of us can second guess what changes might come in in the future and planning ahead has never been more important."
About Tilney
Tilney is a leading investment and financial planning group that builds on a heritage of more than 180 years. Our clients are private investors, charities and professional intermediaries who trust us with over £23 billion of their assets. We offer a range of services including financial planning, investment management and advice and, through our Bestinvest service, a leading online platform for those who prefer to manage their own investments.
We have won numerous awards. Tilney has been awarded Best Conventional Advisory Service at the 2018 City of London Wealth Management Awards, Best Advisory Service in the 2015 City of London Wealth Management Awards; Investment Award – Cautious category in the Private Asset Management Awards; and Stockbroker of the Year, Execution-only Stockbroker of the Year and Self-select ISA Provider of the Year 2015, as voted by readers of the Financial Times and Investors Chronicle. Bestinvest was voted Best SIPP Provider and Best Fund Platform at the 2017 City of London Wealth Management Awards, Best Direct SIPP Provider at the YourMoney.com Awards 2017, Best Stocks & Shares ISA Provider at the 2017 Shares Awards, as well as Best Self Select ISA Provider, Best Online/Execution-only Stockbroker and Best Investment Platform 2017 at the FT and Investors Chronicle Investment and Wealth Management Awards, as voted by readers of the FT and Investors Chronicle.
Headquartered in Mayfair, London, the Tilney Group employs over 1,000 staff across our network of 30 offices, enabling us to support clients with a local service throughout the UK.


text:
Computer just shows background picture when turning on screen
After using my desktop, I return to the main screen by clicking on switch user.
Then I just turn off my screen. When I return to my computer after a while, I turn on my screen and all I see is my background picture. I can't get out of it. The only thing
I can do is move my mouse around on the screen. So, I have to restart my computer everytime I go to get back on it. Can anybody tell me what the problem is or could be and how to fix it?
Keys to the Problem Computer just shows background picture when turning on screen
Download SmartPCFixer to Fix It (Free)
Hi usafguy76,
I need to some details before proceeding.
1. Are you referring to the user account screen when you say "Main Screen"?
2. Do you see the background picture immediately when you turn on the monitor or after logging in?
Step 1: If you have this issue after logging in then try launching Task Manager.
To do so, follow these steps.
a. Press CTRL+SHIFT+ESC on the keyboard.
b. Click "New Task" and in the "Open" text box type "explorer.exe" (without quotes) and press OK.
Check to see if you it opens Windows Explorer.
Step 2: Try updating the chipset drivers for the computer and check if it helps.
Log on to the computer manufacturer website and update all the device drivers.
Please relay more information about the issue and also what happens after you try these steps so we can look into further options.
Syed N – Microsoft Support
Visit our
Microsoft Answers Feedback Forum and let us know what you think.
- Open Internet Explorer.
- Go to "Tools > Internet Options > Advanced Tab".
- Uncheck "Enable third-party browser extensions".
- Click "Apply".
- Reboot your computer.
Another Safe way to Repair the Problem: Computer just shows background picture when turning on screen:
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1. Click the button to download SmartPCFixer . Install it on your system. Open it, and it will scan your computer. The errors will be shown in the scan result.
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text: I spent last weekend in Moncton, Halifax' so called arch rival. I was up there for New Brunswick Music Week. I took my kids, did a panel and a ran a workshop, went to Crystal Palace, ate at the Crowne Plaza. We had a lovely time. A dominant meme in Halifax is that Moncton is outpacing Halifax economically, culturally, and most importantly, in the rare commodity of "can do spirit". The usual suspects in the pro-development at all costs camp read more


text:
Great caravan and great people to deal with!
Great caravan and great people to deal with. Was clean and tidy. The Expanda had a really flexible layout, a shower / toilet, and allowed us with small children to have privacy when we needed it, safe playing areas and visitors. The owners delivered and setup, and packed down and picked up, which really took the stress away from Towing. Thanks again.


text:
One of the true office productivity war horses is about to get a smart makeover.
Microsoft Excel, the venerable business spreadsheet application used for years in enterprises ranging from sole proprietorships to multinational corporations, soon will be able to take your inputs and go them one better, thanks to machine learning and the internet.
As TechCrunch's Frederic Lardinois writes, "Excel will soon be able to understand more about your inputs and then pull additional information from the internet as necessary."
This smarter, proactive version of Excel should be available early next year, but Lardinois got a sneak peek this week from two Microsoft executives at the software giant's Ignite conference in Orlando.
While Excel long has been a valuable component of Microsoft's Office suite of productivity tools, it's lacked the dynamic features found in more modern productivity apps such as collaboration software. But the updated version will incorporate new data types that go far beyond what humans enter into Excel's spreadsheet rows and columns.
Enter a company name into Excel, for example, and an integrated Bing API will search for and add in stock information, market cap, and other data. The new Excel "can even automatically detect that a list of names is indeed a list of company names or a list of cities," Lardinois writes, "which then allows you to pull in population data, among other things."
Finding and injecting relevant data is a great way to turbocharge a spreadsheet and provide more opportunities for enterprise employees to mine information in ways that can improve the business. That includes the use of intelligent graphics; the coming version of Office features a built-in tool that will pull compelling data from Excel to create visualizations.
As Lardinois notes, Google Sheets offers a similar feature, but not everybody uses Google Sheets (or G Suite, Google's competitor to Office). Indeed, in larger enterprises, Office and Office 365 primarily remain the business application suites of choice.
This means that, sometime early next year, millions of enterprise workers will be able to leverage the power of machine learning, the internet, and visualizations within Excel. It's another step toward the day when every enterprise worker is a data analyst.
DXC and Microsoft: The power of partnership
DXC Technology named Microsoft's Productivity Partner of the Year
Take Note: Evernote, Microsoft OneNote, Google Keep and now DropBox


text:
The ferry slowly entered the principal port of Tonosho. Olive oils and cosmetics, foods derived from olives, soy sauce, and somen noodles are known as major products of this island. However, the island is not so highly evaluated as a tourist spot. The cycling tour event, which I'd join tomorrow, was planned by a major travel company and local body of commerce and industry to raise the awareness about Shodoshima among Japanese people.
I'd visited the island nearly 40 years ago from the opposite side of Okayama City. I didn't remember clearly the scene of those days, but the base station of the Kankakei Gorge Ropeway remained as it used to be 40 years ago. Kankakei Gorge is the representative sightseeing spot on the island. I took a walk on the narrow path in the gorge and then the historic streets in a small village. After taking a shower in my hotel, I attended the party of the eve of the event with lots of other strange participants. My wife was going to enjoy sightseeing on the next day, not to ride a bicycle, but by courtesy of the company she enjoyed dinner with me and the performances of local people. Praying for the clear sky of the following day, I hit the sack.


text: Within Africa, ivory is smuggled across borders by truck, bicycle, and even Red Cross vehicle. Then it's shipped to Persian Gulf and Asian nations as unaccompanied baggage, in freight containers with secret compartments, or broken into multiple consignments labeled as cell phone parts, sisal fiber, and cashew nuts. It's a shell game intended to confuse customs authorities, but it's widely believed most large hauls are actually destined for China.


text:
Posted on February 19, 2016
We have an amazing selection of bouquets, planted designs and unusual plants now in stock, and we will be delivering all weekend for those special mums! Order now to guarantee delivery! Or pop in to either Canterbury or Deal shop where we will be happy to help! We have balloons chocolates and teddies too! xx


text:
by John Greene
When He opened the third seal, I heard the third living creature say, "Come and see." So I looked, and behold, a black horse, and he who sat on it had a pair of scales in his hand. And I heard a voice in the midst of the four living creatures saying, "A quart of wheat for a denarius, and three quarts of barley for a denarius; and do not harm the oil and the wine." – Revelation 6:5-6
This scripture foretells great food shortages in the last days. Drought and famine most often come to mind because, in the past, this has been the most common cause for lack of food. Hyperinflation has been posited as a possible cause of famine in the last days, just as it happened with Germany in the 1920s. There is nothing new in radical actions of governments withholding food from residents of their countries, as this was a regular publicized occurrence in the 1980s and 1990s. Imbalances in consumption by prospering countries sometimes create food shortages as do floods and other natural events, as has occurred in the bread basket of the United States this year. Depletion of U.S. and global grain reserves continue unabated. Record crop losses are being glossed over by the USDA. Food shortages are commonly created by financial crisis and extreme weather. ("News: Hyperinflation & False Teaching"; "News: Investment & the Black Horse of Famine")
Now, the pair of scales in the hand of the rider of black horse bears a new significance for the Bible truth seeker. A decade ago, nobody would have guessed a new wrinkle in food shortage, created by the rampant greed of speculators in national and international marketplaces. The number of derivative contracts in commodities increased by more than 500% between 2002 and 2008. This was followed by the collapse of the U.S. mortgage market and economic meltdown. A global recession followed, accompanied by a huge spike in food prices. ("News: The Ten Kingdoms of the New Order")
U.S. Federal Law made the Wall Street foray into food possible. The Commodity Futures Modernization Act of 2000 allowed bidding to begin on the trade of food commodities without limits, disclosure requirements, or regulatory oversight. The Act also permits derivatives contracts, where both buyer and seller speculate on paper, and neither party has any intention of ever physically acquiring the commodity in question. It's outright gambling with the population of the world held captive. It's the same market that brought down the banking industry and created the 2008 economic meltdown. ("Foundation of a Global System of Greed")
"How The Financial Crisis Helped Turn Big Banks Into Global Commodities Kings" — Houston Chronicle , August 4, 2013
"Wall Street Out of Control" — Wall Street Pit, August 2, 2013
The advertising says that agricultural commodities markets were created so that traders of food could hedge their positions against big swings in prices. If you're sitting on a warehouse full of corn, it's worth making a significant bet that the price will go down, just in case it does, and makes your corn worthless. That way at least you make money on the bet to counter the actual loss. Derivatives can add leverage to your bet, so you don't need to bet the entire value of your corn in order to protect it. That is some of the logic being employed in the business world today, which is likely to create another financial bubble if it doesn't create a real shortage through pricing manipulation. ("The Power Behind the New World Order"; "Christians & Finance"; "Approved: Lie Cheat & Steal")
It is just two years since the last crisis. While food prices increased substantially in the United States, a spike in the price of agricultural commodities in 2007-08 caused panic from Italy to Haiti. At the time, Wall Street derivatives and speculation were largely unknown as an underlying cause until later. Today, speculation is a recognized cause, promoted by an increasing "global market."
This contract speculation continues to lift its ugly head. In Niger, a poor west African nation, "is experiencing its worst food crisis in years, but is not actually short of food. Mounds of cereals are piled high on market stalls – they are simply too expensive to afford." In the theory of earthly wisdom, prices of all commodities are impacted by wheat. ("The Image & Mark of the Beast System"; "The Man of Lawlessness"; "Bible Prophecy and the Rise of the Corporation"; "Millenniums of Human Exploitation")
The typical explanation for the high price of food in Niger would be a crisis of production. The media might actually address this as the cause. The truth is that the harvest has been destroyed by extreme weather in wheat-producing powerhouses of agriculture. The rise in prices, especially abroad, has been accompanied by the rise of speculation in commodity markets. Derivatives packaging products such as wheat and corn have created massive profits for speculators without any concern regarding the actual commodities represented by the derivatives.
The recent heatwave, forest fires and drought in Russia and central Asia may be unprecedented in recent times, just like events in the U.S. and China. Nations are often hesitant to admit to price tampering or any pressures outside of supply and demand until they must, as is reflected in the initial reaction of the court system in the Russian government. There is something familiar about the ensuing food crisis, now founded in the price of wheat, which has catapulted by 50%. Speculation has once again reared its ugliness. When high food prices are combined with food shortages, only one result is likely; hunger and starvation in line with Bible prophecy. ("Mind Control of the Beast"; "Delusion & the Tightening Noose of the Beast System")
Food Prices & Supply — New York Times, Continual Update
Global Food Prices Continue to Rise — Worldwatch Institute, April 11, 2013
Wall Street Vultures Drive Up Food Prices While Billions Starve — American Free Press, February 6, 2013
Profiting off hunger: Wall Street makes big gains over food price spikes — RT, January 21, 2013
Food prices may be catalyst for 2013 revolutions — Market Watch WSJ, January 16, 2013
Rising Food Prices: Why Wall Street Is Partially to Blame — Yahoo! Finance, October 16, 2012
Treating food like stocks and shares is a recipe for disaster — Guardian Observer, October 13, 2012
How Wall Street Fuels Global Hunger — Mother Jones, September 16, 2011
The chart below is better titled "Real Food Price Inflation"
from U.S. Agriculture Department April 2013