text:
P- Reviewers: Ersoy O, Iakovidis DK S- Editor: Zhai HH L- Editor: A E- Editor: Zhang DN
Published online Jul 14, 2014. doi: 10.3748/wjg.v20.i26.8416
Revised: January 30, 2014
Accepted: March 12, 2014
Published online: July 14, 2014
Iron deficiency anemia (IDA) is common and often under recognized problem in the elderly. It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract. Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel (SB). Capsule endoscopy (CE) provides direct visualization of entire SB mucosa, which was not possible before. It is superior to push enteroscopy, enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA progressively increases with advancing age, and is highest among patients over 85 years of age. Balloon assisted enteroscopy is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.
Core tip: Iron deficiency anemia (IDA) is a common problem especially in the elderly. Small bowel (SB) lesions may be the source of IDA. Capsule endoscopy (CE) provides direct visualization of entire SB mucosa. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA increases with advancing age. Balloon assisted enteroscopy is used to treat the lesions seen on CE causing IDA.
- Citation: Muhammad A, Vidyarthi G, Brady P. Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature. World J Gastroenterol 2014; 20(26): 8416-8423
- URL: https://www.wjgnet.com/1007-9327/full/v20/i26/8416.htm
- DOI: https://dx.doi.org/10.3748/wjg.v20.i26.8416
Iron-deficiency anemia (IDA) is the most common cause of anemia worldwide, causing significant disease-related morbidity, and has a negative impact on patient's well-being and overall outcome. Anemia is defined by the World Health Organization (WHO) as a hemoglobin concentration of less than 13 mg/dL in men and less than 12 mg/dL in women[1]. The gold standard for the diagnosis of iron deficiency is the absence of iron staining (Prussian blue stain) on bone marrow biopsy. In clinical practice, this invasive test is replaced by evaluation with more readily available laboratory parameters. The classic hallmarks of IDA are low serum ferritin (< 20 ng/L), low serum iron (< 33 g/dL), high serum total iron-binding capacity (> 400 g/dL) and low mean corpuscular volume (< MCV 80 fL).
In the year 2010, 40.3 million people (13.0% of the total population in United States) were 65 years of age and older (elderly), and 5.5 million were above 85 years of age. The elderly population is expected to increase to more than 20% of the total population by 2030, with individuals 85 years and older representing the fastest growing segment of this group. The Third National Health and Nutrition Examination Survey (NHANES III, 1988 to 1994) indicated that the prevalence of IDA was nearly 10.6% in elderly. This means almost 4 million elderly Americans have IDA[2].
IDA is common and often under recognized problem especially in elderly with increased morbidity and mortality. Anemia, however, is not simply a consequence of aging, but also a marker of underlying disease, requiring investigation for an etiology. Anemia is recognized to be associated with increased frailty, poor exercise, performance, diminished cognitive function, dementia, decreased mobility, increased risk for falls, lower bone and muscle density, depression and delirium[3,4]. Anemia is a marker for increased disease-related morbidity, including hospitalization and mortality in elderly[5].
IDA in elderly may be the result of multiple factors. Major considerations include iron deficiency secondary to a bleeding lesion in the gastrointestinal (GI) tract and this is one of the major indications for referral to gastroenterologists (13% of referrals). In clinical practice esophagogastroduodenoscopy (EGD) and colonoscopy are performed in the initial evaluation of IDA to exclude a source of chronic blood loss from the GI tract. Despite undergoing standard endoscopic evaluation, up to 30% of patients with IDA have no definitive diagnosis[6]. Twenty percent of elderly patients have a negative upper and lower endoscopy and two-thirds of them have a lesion in the small bowel (SB)[7]. It is important to investigate the SB in all patients with unexplained IDA, after negative standard dual endoscopic evaluations (ASGE Practice Guideline 2010)[8] (Figure 1).
The original capsule endoscope (PillCam SB) was developed by Given Imaging in 2001[9]. It is a disposable capsule, 11 by 26 mm in size and weighs 3.7 g. There is a set of short focal length lenses located in front of the camera to collect an image in a 140 degree field of view and magnify it by a factor of 8. This optical system provides a resolution of 0.1 mm. The capsule communicates with the external world through a radio transmitter. Each second two pictures are transmitted at 432 MHz to an array of sensors taped to the patient's abdomen. These sensors in turn relay information to a data recording device worn on a belt. The capsule is powered by two silver oxide batteries with a battery life of 8 h. The new capsule (PillCam SB 3) captures up to 6 frames per second with a 30% improvement in picture resolution.
Since the initial presentation at DDW of 2000, the fantastic voyage of capsule endoscopy (CE) has made significant strides[10]. One of the most significant impacts of the CE has been in the elderly, where it provides a less invasive and virtually complete exam. It has expanded our area of visual survey to include direct visualization of entire SB mucosa, which was not possible before. CE had emerged as a ''light in the darkness'' for the identification and localization of SB mucosal diseases[9,11]. It has developed an important role in the investigation of patients with IDA when EGD and colonoscopy are negative.
There are a number of other diagnostic modalities, old and new to evaluate the SB, but they all have limitations. CE has made fluoroscopic imaging of SB almost obsolete[12]. Traditional SB X-ray series have the lowest yield and fail to detect many mucosal lesions. CE is superior to SB enteroclysis for detecting lesions in patients with unexplained IDA and should be the next diagnostic test of choice after unremarkable standard endoscopic evaluation[13].
Although push enteroscopy (PE) offers direct visual inspection of the SB mucosa beyond the reach of the standard upper endoscopes, it reaches only 80-120 cm beyond the ligament of Treitz and its sensitivity in identifying the source of bleeding is limited[14]. CE is superior to PE and SB barium radiography for diagnosing clinically significant SB pathology in patients with IDA[15].
CE is performed as per the standard protocols endorsed by American Society for Gastrointestinal Endoscopy (ASGE)[16]. An informed consent is obtained prior to the procedure. Patients usually present in an out-patient setting, after fasting for 8 h. A bowel preparation is optional. They swallow the capsule with few sips of water in a sitting position. A clear liquid breakfast after 2 h and a light meal after 4 h are permitted. After 8 h, patient returns to the endoscopy unit, the data recorder is removed and images are downloaded to the computer. The recordings are then viewed by an experienced reader.
The common SB findings seen on CE when performed for IDA in elderly are[17]: (1) Angioectasia or arterio-venous malformation (Figure 2A); (2) Ulceration [related to nonsteroidal anti-inflammatory drugs (NSAIDs) or Crohn's disease] (Figure 2B); (3) Tumor or mass lesion (Figure 2C); (4) Celiac disease (CD) (mosaic pattern and scalloping) (Figure 2D); and (5) Active bleeding (Figure 2E).
Angioectasia is one of the commonest found lesion seen on the CE in elderly with IDA. It accounts for 40% of cases of bleeding of obscure origin[18,19] It is seen more commonly in patients with hereditary hemorrhagic telangiectasia, renal disease and in elderly patients with multiple comorbidities[20]. The incidence of angioectasia is about 23%[21]. It varies from a flat lesion greater in diameter than one villus to a pulsatile red protrusion with surrounding venous dilation. They can be treated with argon plasma coagulation or multipolar electrocautery at the time of enteroscopy.
Another common finding, which causes IDA in elderly is the inflammation induced by NSAIDS. The mechanism of action of NSAIDS is COX-1 inhibition and prostaglandin depletion. The Spectrum of NSAID induced SB injury became clear only after the advent of CE, as before 2000 this knowledge was available only from case reports and autopsy series. NSAID induces ulcers may be single or multiple. NSAID induced strictures can be a cause of capsule retention if the stricture was not suspected before administering the capsule. The differential of NSAID induced ulceration includes Crohn's disease, CD (ulcerative jejuno-ileitis), infection (Cytomegalovirus, Tuberculosis, Yersinia), radiation, ischemia, vasculitis and chemotherapy (mucositis)[22].
CD is another condition where the diagnosis is frequently missed. Because of the increased prevalence of undiagnosed CD (iceberg effect), any test that has a promise of increased detection is of great interest. IDA may be the only manifestation of CD in elderly. Another utility of CE in elderly with CD lies in patient population with refractory CD to evaluate for malignancy such as lymphoma, carcinoma and GISTs. SB tumors are a relatively uncommon diagnosis and account for 3% of all GI malignancies. After gastrointestinal stromal tumor (GIST), adenocarcinoma of the SB is the most common malignancy found in the elderly. In a study of 5129 patients, 129 (2.4%) were found to have SB malignancy[23]. Current data suggests that CE can shorten the diagnostic work up for SB tumor and can influence further management and outcome.
Given the second peak of Crohn's disease in the elderly, CE can play an important role in the diagnosis of this condition. CE can detect minor (distorted villi, erosion or scars) or major changes (ulcers or strictures) related to Crohn's disease[24].
The DY of CE in the evaluation of unexplained IDA progressively increases with advancing age, and is highest among patients over 85 years of age. This may be explained by the fact that ASA, NSAIDs, and warfarin usage is more common in elderly as compared with younger patients. Elderly patients with high diagnostic yield (DY) for IDA are likely to benefit more from CE than younger patients. IDA in the elderly with or without obscure GI bleeding (OGIB) is the major indication for CE after a negative EGD and colonoscopy.
There have been a numbers of papers written on the DY of CE when performed for IDA (Table 1). However, there are only few studies which specifically reported on the DY in elderly, and have shown that it is significantly higher as compared to younger age group. Sidhu et al[25] performed a retrospective review of 779 consecutive patients that underwent CE over a 7-year period (2002-2009) for OGIB and recurrent IDA. The DY of CE in elderly was 53%. The most common diagnosis in the elderly was angioectasia (34%). When compared to younger patients, the DY was significantly higher in elderly for IDA (51% vs 37%, P = 0.003, OR = 1.8, 95%CI: 1.3-2.5). Management was also altered in a significant greater proportion in the elderly (P = 0.002, OR = 1.8, 95%CI: 1.3-2.5). The authors finally concluded that CE has a positive impact on the management of IDA in elderly and there should be no barrier to performing CE in this age group. The authors of this study published another paper recently where they reported the DY of CE for IDA is significantly higher in patients who were aged 70 years or older (P < 0.001, OR = 1.9, 95%CI: 1.4-2.6)[26].
|Total patients
|Patients with positive findings (DY)
|Inflammatory lesions (erosions/ulcers)
|Mass lesions
|Active bleeding
|Other findings (celiac disease, Crohn's disease)
|Holleran et al[46]
|35 (53)
|17 (49)
|12 (34)
|4 (11)
|2 (6)
|Sidhu et al[26]
|245 (42)
|141 (58)
|16 (11)
|Tong et al[47]
|25 (26)
|6 (24)
|16 (64)
|2 (8)
|1 (4)
|Koulaouzidis et al[48]
|68 (31)
|49 (72)
|19 (28)
|Yamada et al[49]
|19 (63)
|6 (20)
|7 (37)
|2 (12)
|4 (21)
|Efthymiou et al[50]
|15 (38)
|Milano et al[51]
|35 (78)
|13 (37)
|9 (26)
|6 (17)
|7 (20)
|Goenka et al[52]
|35 (37)
|Katsinelos et al[53]
|13 (34)
|6 (46)
|4 (31)
|1 (8)
|2 (15)
|Riccione et al[54]
|91 (66)
|51 (56)
|18 (20)
|9 (10)
|13 (14)
|Van Turenhourt et al[55]
|106 (44)
|Laine et al[56]
|13 (33)
|4 (31)
|9 (69)
|Sheibani et al[57]
|35 (61)
|21 (60)
|4 (12)
|5 (14)
|5 (14)
|Kim et al[58]
|12 (48)
|8 (66)
|2 (17)
|2 (17)
|Sidhu et al[25]
|152 (48)
|84 (56)
|25 (16)
|10 (6)
|33 (22)
|Muhammad et al[27]
|127 (55)
|35 (28)
|64 (50)
|15 (12)
|13 (10)
|Chami et al[59]
|4 (33)
|Carey et al[60]
|62 (46)
|35 (56)
|16 (26)
|4 (6)
|7 (12)
|Apostolopoulos et al[61]
|29 (57)
|12 (41)
|13 (45)
|4 (14)
|Estevez et al[62]
|30 (63)
|Van Tuyl et al[63]
|49 (33)
|Qvigstaad et al[64]
|11 (28)
|Kalantzis et al[65]
|27 (42)
|De Leusse et al[66]
|6 (30)
|Ben Soussan et al[67]
|7 (38)
|Enns et al[68]
|7 (50)
|2 (29)
|3 (42)
|2 (29)
|Fireman et al[69]
|37 (52)
|18 (49)
|11 (30)
|8 (21)
|Pennazio et al[17]
|19 (44)
|4 (21)
|9 (47)
|6 (32)
Similarly, we have also published on the DY of CE for IDA which was found to be 69% among patients of > 85 years of age and 56% for the age group of 65-85 years[27]. In another study, we have reported on the utility of CE in the diagnosis of CD in elderly for the first time, when they presented for IDA. We found that out of 279 elderly patients with IDA, 7 (2.5%) had mucosal abnormalities suggestive of CD (atrophy, scalloping, mosaic pattern, layering, and nonspecific ulcerating jejuno-ileitis). Subsequent evaluation with serum antibody testing +/- multiple distal duodenal biopsies confirmed the diagnosis in all patients[28].
Recently Koulaouzidis et al[29] published a systematic review on the DY of CE for IDA in all age groups. The pooled DY of CE in studies focused solely on patients with IDA was 66.6% (95%CI: 61.0%-72.3%).
CE has a number of advantages compared with deep enteroscopy especially in elderly patients. These include the potential ability to visualize the entire SB with a non-invasive procedure carrying a minimal risk of complications, a high sensitivity for lesions and high patient acceptance. These advantages make CE the preferred initial procedure for evaluation of IDA. However, it also has a number of disadvantages including the lack of biopsy and therapeutic capability, the potential for retention above a stricture, and the potential for missed lesions. The overall miss rate for CE is estimated to be 10%-30% in patients with OGIB, and solitary lesions are more likely to be missed[30]. Deep enteroscopy is needed in patients with continued IDA despite a negative CE, and for biopsy and therapy of lesions demonstrated by CE.
The currently available types of enteroscopy include PE, intra-operative enteroscopy (IOE), balloon assisted enteroscopy (BAE), and spiral enteroscopy (SE). PE has limited applicability because only the duodenum and proximal jejunum can be visualized. IOE has the capability of visualizing the entire SB but carries a significant operative morbidity, and a mortality of up to 4%[31]. SE is a promising new technique which allows deep enteroscopy in a shorter period of time than BAE. This shortens anesthesia time which may be a significant advantage in the elderly. However, it is not widely available, and the system is not currently being sold while modifications to enhance its utility are being developed. This leaves BAE as the most viable option for deep enteroscopy. The greatest advantage of BAE is the ability to biopsy and tattoo the lesion seen on the CE (Figure 3). Other advantages include the therapeutic benefit which includes hemostasis, polypectomy, balloon dilation of strictures and foreign body removal. The disadvantages are that it is invasive with higher risks for complications, time consuming, requires sedation and the entire SB is not visualized in one procedure. When used by both oral and anal route in a given patient, it has the potential to visualize the entire SB.
In two prospective randomized studies of double balloon enteroscopy (DBE) vs single balloon enteroscopy, total enteroscopy was achieved more frequently with DBE. However, there was no difference in DY or therapeutic outcome between the two techniques[32-34]. BAE is frequently a long procedure lasting 60 min or more, and requires deep sedation. Elderly patients may be at increased risk for complications due to prolonged endoscopic procedures, and prolonged sedation due to co-morbidities such as cardiac and pulmonary disease. In addition they are at greater risk of aspiration, have an increased response to sedatives, and have a blunted response to hypoxia and hypercarbia[35]. The complications of BAE include perforation, pancreatitis, and GI bleeding. These occur in 1%-2% of patients which is a higher complication rate compared with standard endoscopic procedures (EGD and colonoscopy)[36,37]. There are only few studies reported on the safety and efficacy of BAE in elderly patients. In a single center, retrospective study on the efficacy and safety of DBE, a total of 60 patients older than 75 years with 110 younger patients were evaluated[38]. Elderly patients were more likely to have angioectasia (39% vs 23%, P = 0.01), and to require endoscopic therapy (48.6% vs 29.2%, P = 0.01). The overall complication rate was 0.9% with no serious complications. There was no difference in the success and complication rates in both age groups in this study.
In another retrospective study, 137 patients (80 years or older) underwent DBE after CE. The correlation between the findings on CE and DBE occurred in 78.9% of patients. False negative findings on CE were present in 6 patients with false positive findings in 18 patients. The DY for DBE in patients with OGIB was 90.2%. No complications related to DBE were encountered in these octogenarians in the 48 h following the procedure. The authors finally concluded that DBE was safe in octogenarians, and that elderly patients with positive findings on CE should be considered for DBE[39].
The majority of studies have reported a good correlation between the findings at capsule endoscopy and BAE and a comparable yield of positive findings[40]. In general, they can be considered "complementary studies". BAE may be contraindicated in some elderly patients with severe cardiopulmonary co-morbidities. For these reasons, CE should be the first investigation in elderly patients with IDA and other suspected disorders requiring endoscopic SB visualization. BAE is needed for therapy, biopsy and marking of lesions requiring surgery.
A cost-effectiveness analysis for diagnosis of IDA in elderly favors CE over BAE and other radiologic studies. A cost-effectiveness analysis for management of bleeding favors BAE over all other therapeutic modalities. CE is patient friendly, guides BAE approach in positive studies, and predicts a low re-bleeding rate in negative studies. BAE is invasive and requires significant resources and time. It may be occasionally needed to extract a retained capsule endoscope at the SB stricture. Finally, BAE should be considered in patients with a negative CE who continue to have unexplained IDA and OGIB.
CE enables visualization of the entire SB but lacks the potential for therapeutic intervention. Other limitations include inability to provide precise location of a lesion, false-positive results, potential for erratic passage resulting in missed lesions and limited battery life causing incomplete studies.
CE is a very safe procedure with few reported adverse events. There have been concerns about the theoretical interaction of CE with cardiac defibrillators, although no adverse events have been reported in the literature[41,42]. Inability to swallow the capsule, battery failure before capsule reaches the cecum, and capsule retention are some of the important problems associated with CE in elderly as well as in younger patients[43]. In patients who are unable to swallow the capsule, it can be successfully placed in the duodenum by using a capsule delivery device. In patients with suspected SB stricture, a new capsule (AGILE Patency system by Given Imaging) is available, which can be given before SB capsule to evaluate for SB patency[44]. The true remaining contraindications to CE are SB obstruction/pseudo-obstruction and pregnancy[45].
The use of GI endoscopy in geriatric patients is increasing as a larger proportion of the population is reaching an advanced age. IDA is a major problem in elderly and requires further evaluation and management. SB CE plays an important role in the evaluation of IDA in all age groups, especially in the elderly with a very high DY. SB angioectasia, ulceration, tumor, CD and active bleeding are the common findings seen on CE in elderly with IDA. BAE is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.
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|Orlando G, Luppino IM, Lerose MA, Gervasi R, Amato B, Silecchia G, Puzziello A. Feasibility of capsule endoscopy in elderly patients with obscure gastrointestinal bleeding. An up-to-date report. BMC Surg. 2012;12 Suppl 1:S30. [PubMed] [DOI]
|Signorelli C, Rondonotti E, Villa F, Abbiati C, Beccari G, Avesani EC, Vecchi M, de Franchis R. Use of the Given Patency System for the screening of patients at high risk for capsule retention. Dig Liver Dis. 2006;38:326-330. [PubMed] [DOI]
|Storch I, Barkin JS. Contraindications to capsule endoscopy: do any still exist? Gastrointest Endosc Clin N Am. 2006;16:329-336. [PubMed] [DOI]
|Holleran GE, Barry SA, Thornton OJ, Dobson MJ, McNamara DA. The use of small bowel capsule endoscopy in iron deficiency anaemia: low impact on outcome in the medium term despite high diagnostic yield. Eur J Gastroenterol Hepatol. 2013;25:327-332. [PubMed] [DOI]
|Tong J, Svarta S, Ou G, Kwok R, Law J, Enns R. Diagnostic yield of capsule endoscopy in the setting of iron deficiency anemia without evidence of gastrointestinal bleeding. Can J Gastroenterol. 2012;26:687-690. [PubMed]
|Koulaouzidis A, Yung DE, Lam JH, Smirnidis A, Douglas S, Plevris JN. The use of small-bowel capsule endoscopy in iron-deficiency anemia alone; be aware of the young anemic patient. Scand J Gastroenterol. 2012;47:1094-1100. [PubMed] [DOI]
|Yamada A, Watabe H, Yamaji Y, Yoshida H, Omata M, Koike K. Incidence of small intestinal lesions in patients with iron deficiency anemia. Hepatogastroenterology. 2011;58:1240-1243. [PubMed] [DOI]
|Efthymiou M, Allen PB, Jayasekera C, Taylor PV, Taylor AC. Value of fecal occult blood test as a screening test before capsule endoscopy. Eur J Gastroenterol Hepatol. 2011;23:690-694. [PubMed] [DOI]
|Milano A, Balatsinou C, Filippone A, Caldarella MP, Laterza F, Lapenna D, Pierdomenico SD, Pace F, Cuccurullo F, Neri M. A prospective evaluation of iron deficiency anemia in the GI endoscopy setting: role of standard endoscopy, videocapsule endoscopy, and CT-enteroclysis. Gastrointest Endosc. 2011;73:1002-1008. [PubMed] [DOI]
|Goenka MK, Majumder S, Kumar S, Sethy PK, Goenka U. Single center experience of capsule endoscopy in patients with obscure gastrointestinal bleeding. World J Gastroenterol. 2011;17:774-778. [PubMed] [DOI]
|Katsinelos P, Chatzimavroudis G, Terzoudis S, Patsis I, Fasoulas K, Katsinelos T, Kokonis G, Zavos C, Vasiliadis T, Kountouras J. Diagnostic yield and clinical impact of capsule endoscopy in obscure gastrointestinal bleeding during routine clinical practice: a single-center experience. Med Princ Pract. 2011;20:60-65. [PubMed] [DOI]
|Riccioni ME, Urgesi R, Spada C, Cianci R, Pelecca G, Bizzotto A, Costamagna G. Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy? Dig Liver Dis. 2010;42:560-566. [PubMed] [DOI]
|van Turenhout ST, Jacobs MA, van Weyenberg SJ, Herdes E, Stam F, Mulder CJ, Bouma G. Diagnostic yield of capsule endoscopy in a tertiary hospital in patients with obscure gastrointestinal bleeding. J Gastrointestin Liver Dis. 2010;19:141-145. [PubMed]
|Laine L, Sahota A, Shah A. Does capsule endoscopy improve outcomes in obscure gastrointestinal bleeding? Randomized trial versus dedicated small bowel radiography. Gastroenterology. 2010;138:1673-1680.e1; quiz e11-2. [PubMed] [DOI]
|Sheibani S, Levesque BG, Friedland S, Roost J, Gerson LB. Long-term impact of capsule endoscopy in patients referred for iron-deficiency anemia. Dig Dis Sci. 2010;55:703-708. [PubMed] [DOI]
|Kim S, Kedia PS, Jaffe DL, Ahmad NA. Impact of capsule endoscopy findings on patient outcomes. Dig Dis Sci. 2009;54:2441-2448. [PubMed] [DOI]
|Chami G, Raza M, Bernstein CN. Usefulness and impact on management of positive and negative capsule endoscopy. Can J Gastroenterol. 2007;21:577-581. [PubMed]
|Carey EJ, Leighton JA, Heigh RI, Shiff AD, Sharma VK, Post JK, Fleischer DE. A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding. Am J Gastroenterol. 2007;102:89-95. [PubMed] [DOI]
|Apostolopoulos P, Liatsos C, Gralnek IM, Giannakoulopoulou E, Alexandrakis G, Kalantzis C, Gabriel P, Kalantzis N. The role of wireless capsule endoscopy in investigating unexplained iron deficiency anemia after negative endoscopic evaluation of the upper and lower gastrointestinal tract. Endoscopy. 2006;38:1127-1132. [PubMed] [DOI]
|Estévez E, González-Conde B, Vázquez-Iglesias JL, de Los Angeles Vázquez-Millán M, Pértega S, Alonso PA, Clofent J, Santos E, Ulla JL, Sánchez E. Diagnostic yield and clinical outcomes after capsule endoscopy in 100 consecutive patients with obscure gastrointestinal bleeding. Eur J Gastroenterol Hepatol. 2006;18:881-888. [PubMed]
|Van Tuyl SA, Van Noorden JT, Kuipers EJ, Stolk MF. Results of videocapsule endoscopy in 250 patients with suspected small bowel pathology. Dig Dis Sci. 2006;51:900-905. [PubMed] [DOI]
|Qvigstad G, Hatlen-Rebhan P, Brenna E, Waldum HL. Capsule endoscopy in clinical routine in patients with suspected disease of the small intestine: a 2-year prospective study. Scand J Gastroenterol. 2006;41:614-618. [PubMed] [DOI]
|Kalantzis N, Papanikolaou IS, Giannakoulopoulou E, Alogari A, Kalantzis C, Papacharalampous X, Gabriel P, Alexandrakis G, Apostolopoulos P. Capsule endoscopy; the cumulative experience from its use in 193 patients with suspected small bowel disease. Hepatogastroenterology. 2005;52:414-419. [PubMed]
|De Leusse A, Landi B, Edery J, Burtin P, Lecomte T, Seksik P, Bloch F, Jian R, Cellier C. Video capsule endoscopy for investigation of obscure gastrointestinal bleeding: feasibility, results, and interobserver agreement. Endoscopy. 2005;37:617-621. [PubMed] [DOI]
|Ben Soussan E, Antonietti M, Hervé S, Savoye G, Ramirez S, Lecleire S, Ducrotté P, Lerebours E. Diagnostic yield and therapeutic implications of capsule endoscopy in obscure gastrointestinal bleeding. Gastroenterol Clin Biol. 2004;28:1068-1073. [PubMed]
|Enns R, Go K, Chang H, Pluta K. Capsule endoscopy: a single-centre experience with the first 226 capsules. Can J Gastroenterol. 2004;18:555-558. [PubMed]
|Fireman Z, Eliakim R, Adler S, Scapa E. Capsule endoscopy in real life: a four-centre experience of 160 consecutive patients in Israel. Eur J Gastroenterol Hepatol. 2004;16:927-931. [PubMed]


text: Last night I finally found a bit of quiet time for myself, time to find the space where I could speak the words I needed to speak and listen for what would come my way. Those times never feel long when I am in that space, hours passing in minutes. The answers usually come if I take the time to listen and see, and so they did, rather boldly this time, quieting my doubts and uncertainties. It was time much needed and when my head hit the pillow in the wee hours of the night I felt a closeness that had not been there in days.

subset: commoncrawl


text:
In the market data section, I've checked "adjust for dividends"
For the relevant instrument, I've manually entered the dividend amounts on the ex-div date.
I enter the ticker on a chart.
However, the price on the chart still appears to drop by the dividend amount on each ex-div day.
In fact, I just tried unchecking the "adjust for dividends" box and the prices don't appear to be any different than when the "adjust for dividends" box is checked.
Any idea what I'm missing here?


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Pat Eakets is now run by Rebecca Herbert, an ex pupil of the school and a fully qualified teacher with The B.T.D.A. (The British Theatre Dance Association). Trained in First Aid and fully CRB checked. Dance qualifications to advanced level in Ballet, Tap, Modern, Street Dance and Musical Theatre.
07806 990 927 / firstname.lastname@example.com


text:
spring car seat cover - orange
It's simple. It goes on like a shower cap, over the top of the seat not compromising the safety or function of
the harness system. No extra padding has been added behind the baby.
It goes on like a 'shower cap' over the top of the infant car seat. No extra padding has been added behind the baby. This car seat cover does not interfer with the harness system.
The elasticized sides creates a snug fit around the car seat. This baby parka fits all Canadian approved infant car seats.
The buckle me label is a friendly reminder to those of us who are sleep deprived.
Reflective tape is used on our products because we know it can get darker when it rains. When using a stroller or carrier, the baby enters the intersection ahead of you. It makes baby and you more visible to drivers.
The transition from outside to inside with a sleeping baby is made easy...simply pull the cover off the car seat without disturbing your baby.
The exterior is water repellent with a soft hand, 100% nylon taslan. Easy to care for. Machine wash cold and air dry.
Adapability, tuck a blanket on top of your baby (buckle baby in and then lay blanket on top) and then put the cover on.
Made in Canada.


text:
Happy Happy Birthday!!
It's this beautiful daughter's birthday!
What a special woman she is!
She is an amazing big sister to Jensen and Alec.
She puts all she has into her 3rd grade class.
She loves those kids, goes the extra mile to make learning
fun, and would do anything for them.
She has a big heart and cares deeply for others.
She is a strong/independent woman!
Has a huge love for the gospel and her Savior.
Love her humor and sarcasm.
She has always worked hard at anything she does.
She has grown and matured into an incredible woman!
She is fiercely loyal.
She is always willing to help out.
We are so proud of Mackenzie!
She is an incredible daughter.
We are so blessed to be her parents!
Have a fabulous day!
We Love you!
Mom and Dad


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CHAMP (Children, Healthy and Active! Multi-Agency Programme) a GHA initiative, will be running a free cooking session for children between the age of 8-12 years this Friday 18th January.
The cooking session will be held in the catering facility by Westside school at 4:30pm where children will be cooking 2 dishes with a parent/guardian. All the necessary ingredients have been provided by Eroski Supermarket, who are also sponsors of the event.
A spokesperson for the initiative said that "The purpose is to give confidence to the children in the kitchen and teach them that foods people see as unhealthy can be made healthy by choosing the right ingredients and ensuring portion control is kept."


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New York
Sotheby's Evening sale carried the lowest presale estimate since 2009, and, while realizing £49.9 M against a £41.8 M – £59.6 M estimate, with just four lots going unsold; this Evening sale was down by 36.7% against laste year. Sotheby's relied heavily on three works that had been looted by the Nazis and restored to Gaston Lévy, including the highest estimated lot this year: an £8 M – £12 M neo-Impressionist Camille Pissarro painting of peasants working in a field.
Sotheby's Post-War and Contemporary Art Evening sale featured Hockney's The Splash which fetched £21M (without premium), barely reaching the low estimate of £20M. Still, the price is nearly eight times the achieved when the work last sold at auction for £2.9 million in 2006. A good result for the Hong Kong billionaire seller, Joseph Lau, who in 2014 was convicted of bribery and money-laundering in Macao.
Recent Posts


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Oschadbank agrees with creditors to defer payments for 7 years
14:08, 18 June 2015Economy
71 0
State-owned bank Oschadbank has agreed with the special committee of creditors to extend payments under its external debt maturing in 2016, 2017 and 2018 worth $1.3 billion for seven years, to 2023, 2024 and 2025, respectively, the press office of the bank has reported.
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Make our ice lollies into a smoothy bowl!
November 16, 2019 / /
Did you know you can turn our ice lollies into a smoothy bowl?
Take our tropical, mango or blueberry mango ice lolly. Let it melt in a bowl, voila, you have the base of your smoothy bowl. Unlike most Popsicles, our ice lollies are just puree fruit and veggies so when it melts it is creamy and thick. Now add whatever nuts or fruit, you like to your smoothy bowl. Breakfast is served.
TAGGED AS: blueberry, healthy popsicles, ice lollies, mango, smoothy, smoothy bowl, smoothy breakfast, tropical


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Monday, October 7, 2013
The Cost of Getting Started with Space Marines
So I was wondering what it would cost to get started in 40K as Space Marines now. So I worked up a quick list of some basic units to see. So we have 1 commander, 1 dreadnought, 2 tac squads 10 man, 2 rhinos, 1 scout squad 5 man, 1 Assault squad 5 man, 1 landspeeder, and 1 predator. That will kit out to about 1000 points with some very limited options. Add in the just the rules book and the new codex and you line up at almost exactly 400 dollars. I am not including paints, tools, glue, etc. Just a very basic playable force and the rules. That is getting to be real money. If you are playing with a friend can you really tell them that 400 dollars to get started is the way to go for gaming.
For X-wing which I thought has pretty expensive parts 410 dollars you can get 2 starters, add an addition X-Wing and Tie Fighter, 2 of each of the Y-wings, A-Wings, B-Wings, Tie Advanceds, Tie Interceptors, Tie Bombers, Hawk and then 1 each of the Falcon, Slave 1, and Shuttle. Essentially everything you need to play a huge variety of lists especially on the rebel side. As Most of us get into these games through networks of friends and selfishly you want as many friends to play as possible but with 400 dollars to start not an easy introduction.
The new space marine strike force can get you started for less but since it is fixed you probably will end up adding more units faster and having other not used. They do not currently list a space marine battleforce so no option there. Maybe you do not mind Dark Angels even though your friend told you new Space Marines are better that probably knocks you down to 300 but that is still a pretty big investment. Even if you roll back to the vary minimum to play the game which is the starter box and codex you are now at 150 dollars compared to 90 at the last edition. 66% increase in the bare minimum start up cost. While GW knows that their stuff is addictive like crack to the right people they seem to have forgotten that you got to get people that first taste at a level where they will take it home and get started. I wonder if the Redshirts immediately start to upsell on the starter boxes thinking that their is a good chance they will never see the customer again or do they down play the additional costs like lacking the real unit rules in the starter box. I bet they play it by ear and respond to price concerns by downplaying all the missing stuff while try to upsell those who do not flinch at the 100 dollar starter box.
Is there a better way for GW to do this? I wonder if they started something like buy a battleforce and army codex and get a free download of the game rules. You still get 150 dollars out of the player to get the basic start going but they have more freedom in terms of picking that first army and you are getting that money without pushing so many extra starter set minis onto the secondary market. The battleforces do not come with a commander normally so add in another 20 later. This method also would be better for GW since it is useful to new players but essentially useless to the existing players base after the first time unlike the 60 dollar Black Reach set which probably depressed sales of terminators, tactical squads, and dreadnoughts. Maybe it only cuts like 50-80 dollars off the start up but might even it out between the different races and get more people starting with a non space marine army which they will probably add a space marine army since everyone has one of those. Would a promotion like that be helpful to beginners?
5 comments:
I think that would be helpful. An alternative would be to put unit rules, stats and points cost, plus army special rules, in the box with the minis. This way a beginner could buy two troops and an HQ and get started without having to buy a codex.ReplyDelete
It strikes me that the 'one click' purchase system GW currently love could then be used to buy armies at set points levels 500, 750, 1000 and 1500. They could easily put a variety of armies on the web at no extra cost to themselves, and with the rules in the box people wouldn't need a codex to get started (though they would inevitably get one later to use more options).
Imagine a ready to go 600 point box, with army rules, at a GW store. It would be a perfect gift and a great way to start an army, better than Dark Vengeance for the player who already has friends with the rules.Replies
I think that they missed an possible solution when they put out the rules as a ~50 dollar hard cover. Now anything they want to do there is going to be undermining its sales.Delete
The closest thing right now GW offers is the Space Marine strike force, which is actually a nice box. you get 1 commander, a command squad, 2 tac squads a sniper squad assault squad, a venerable dread, razor back and droppod for 250 bucks. it's not perfect and lacks the rules but if someone was just starting space marines it'd definatly be my "reccomendation to start"ReplyDeleteReplies
I mention the Strike Force in the post but add in the 110 dollars for rules and you are still at 360 and that is essentially a single purchase. That takes some serious commitment.Delete
ohh agreed. long term I think GW is in for troubles with their pricing. it's going to make people getting into the game step back and go "wtf"Delete


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StreamSend: Engineering Director
Location: San Francisco, CA
URL: http://www.streamsend.com
Engineering Director (Ruby on Rails)
Job Specifics
- Reports to: President
- Supervises: Engineers
- Travel: Very little if any
Position Purpose
Working director that establishes manages and participates in Agile/Lean product development in a multi-product engineering or multiple major feature-engineering environments.
Duties and Responsibilities
- Actively participate in engineering
- Provide leadership and mentoring to the software engineering team
- Ensure engineering uses Agile/Lean principles for rapid iterations
- Create an environment that promotes engineering to directly understand customer needs, ensuring that products / features fulfill the needs of the customer
- Collaborate with Marketing, Sales, and Support teams as part of engineering process.
- Manage and drive software roadmaps. Establish timelines for engineering and deployments.
- Making key architecture decisions in conjunction with other technical departments. Understanding the on rapid iterations.
- Bachelors degree or greater in Computer Science
- The ideal candidate is one that has had at least 15 years experience in software engineering
- At least 5 years experience in engineering management
- Has worked with a several small companies offering a SaaS product
- Managed small teams with simultaneous product or major feature development
- At least 3 years experience with Ruby on Rails
To apply: Apply Here: http://www.applytracking.com/x.aspx?track=2aNq0Lh7wH6hceBVn5GTaqimqjpjsRbvdScjRpgmSntmWkGinRdur1YkREALykzRLwn%2f25%2b39rsyftVpnDpqbjlaUtkqJFgW
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Read some of the comments made by our previous happy clients
From the moment we met Cheryl we knew we were in good hands and that she genuinely cares about her clients. She is so friendly I felt we had known her forever…and her knowledge is bar none.
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Buying, selling and especially moving are very stressful; but with Cheryl as part of your team you have nothing to worry about. I would not hesitate in recommending her to my friends and family.
We can't thank you enough Cheryl and look forward to working with you again.
Norma M. & Carol V.
I approached Cheryl Johns because… We have used her in the past and always had Excellent professional help
She helped me by… Getting us a mortgage we were happy with
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One thing I liked was her… Professionalism
I found the experience… 100% Excellent
I would recommend Cheryl to people who need… A new Mortgage or to renew their mortgage
When my husband and I decided to put an offer in on a house, things happened very quickly and we weren't fully prepared with our financing. We were first time homebuyers and figuring things out as we went. Cheryl was extremely helpful in pulling everything together in time for our conditions to be met. She is super personable and very accessible to communicate with – plus, she got us a great rate for our mortgage.
I have been using Cheryl for over a decade now and she was recommended to me by an old trusted friend. Having never dealt with a mortgage specialist before I was a bit hesitant. How could it be possible that Cheryl could negotiate better rates? Wow, was I surprised. The first time I used her she managed to knock several percentage points off the rate I had been paying at XXX. On the second occasion she got me a lender that was ver flexible with payment options when I was fortunate enough to inherit a small legacy to help with my mortgage. And my most recent dealings with her for bridge financing–well let's just say she did the nearly impossible. Honestly she has made such a huge difference in my financial situation by negotiating such good rates that even as a single income earner I could put money aside and make occasional lump sum payments. Over the period of my various mortgages thanks to her I have saved thousands of dollars. Cheryl you are the best and I will always come to you for any mortgage related needs and rest assured all my friends will too!
This lady is one amazing mortgage broker. I would recommend her to all my friends.
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Cheryl has helped us twice with mortgages and has been nothing short of amazing. She's always made us feel welcome at her office or even her home when in a time crunch. She's consistently gotten us great rates and made it possible for us to live in the area we have had our eye on for ages.
Whenever someone is looking to secure a mortgage, I always suggest Cheryl. She saved our bacon wth our first mortgage when our original broker dropped the ball, she told us exactly what was needed and got us a mortgage within a weekend. I love that we can contact her at any time and she is so fantastic. She continually goes above and beyond.


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It is easy to see the zeal displayed by a Paul or a Daniel and become discouraged, feeling we do not measure up. How can we show our zeal for God and His way?
Jesus' driven, untiring work exemplifies the concept of zeal in Scripture: as holy fervor—virtuous wrath against evil and great ardor for doing good.
Are we giving our all for Christ and the way of life that God has revealed to us? Are we giving our all for the Kingdom of God? Are we truly zealous?
As we have seen in Parts One and Two, Christian zeal is an interest, an earnest desire, and a pursuit of all that pertains to God, His way, and His Kingdom. ...
Zeal has been discredited as the tool of the charlatan, but Christians must develop passion and zeal for the Christian way of life and the Kingdom of God.
Rather than having an apathetic relationship toward God, we must ardently, earnestly, and fervently seek God in order to imitate His behavior in our lives.
Living faith has its roots in fervently, diligently seeking God and His righteousness with intense desire (like a passionate lover) through habitual prayer.
Persistence in prayer does not mean an incessant pestering God into action. God always looks at our petitions from the vantage-point of His purpose.
It is dangerous to judge something on the basis of apparent 'sincerity,' which is often the opposite of godly sincerity. Godly sincerity is paired with the truth.
We sometimes mistake faith for certainty about God's will. However, faith is not knowing what God will do in a situation but trusting Him to do what is best for us.
The Apostle John exhorts us to test and discern the spirits, judging between the true and the false, using the scripture as the steady standard of truth.
John Ritenbaugh reiterates that only God, not man, can determine whether something or someone is holy or authentic as opposed to profane and strange. God will accept only what He has set apart or designated as holy or authentic, such as the sacred fire in . . .
Richard Ritenbaugh insists that, as Christ's disciples, we have been called for a life of sacrifice'sacrificial giving as a way of life (Romans 12:1). Often we fail to grasp: 1) the desperate emotion expressed by Paul in the word beseech, 2) why he so urge. . .
John Ritenbaugh, focusing upon the scattering of the greater church of God, examines this event within the context of a larger global disintegration of religious influence. The moral agenda of this country and others is set by non-religious organizations a. . .
At the beginning of chapter 18, Paul arrives in Corinth, befriended by Roman expatriates Priscilla and Aquila, devout individuals very important in Paul's ministry, both economically and spiritually. Paul's spirits are additionally revived and energized at. . .
Receive Biblical truth in your inbox—spam-free! This daily newsletter provides a starting point for personal study, and gives valuable insight into the verses that make up the Word of God. See what over 145,000 subscribers are already receiving.


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Proving Yourself for the Performance Review
It's performance review season! For many of us, this can be a stress-inducing experience, but really those key performance reviews can serve as a huge opportunity for growth and development.
Last year, I walked into my supervisor's office holding my breath. I'd been told repeatedly that information on my performance review would "not be news to me," but that still didn't wash away the lingering stress. I sat down in the chair across the desk from my supervisor and she started with, "I actually had to change your performance review score from 'meets expectations' to 'exceeds expectations'. I had forgotten about everything you did this year!"
Until that moment, I thought the self-evaluation my employer required was annoying and monotonous. But as it turned out, the act of reviewing my own achievements over the course of the year served as a tool to advocate for myself even before my performance review began!.
Here's how to prepare for your performance review #likeaboss:
Ask to perform a self-evaluation.
If your employer does not require one, you can ask your supervisor if you can complete one. A performance review is a great time to have a two-sided conversation about how you can improve your performance. Completing and sharing your own self-evaluation is an excellent way to start the conversation. Even just having a copy of the document you are reviewed with can help you ensure you're meeting your marks.
Complete your self-evaluation early.
Completing your self-evaluation early in the performance review process is important. If you are going to send the document to your supervisor, you want them to have received it before they complete your evaluation. This makes it easier for them to review your work, while also giving them direction on what you want to focus on.
Think critically prior to completion.
A self-evaluation isn't a document you'll be able to complete in a half hour. The self-evaluation can be a way to open the conversation to discussing a raise, a promotion, or professional development opportunities. Start your process by completing a brain dump of everything you've done since your last evaluation. After your initial brain dump, start to sort these project or tasks out chronologically and fill in the gaps between them. Highlight the things you want included in your review. When you start writing and scoring yourself, keep this list close by.
Use tangible examples.
You can tell your supervisor about how excellent you are all you want, but if they don't remember the things that made your performance excellent it doesn't really matter. Use examples in your self-evaluation that remind them of that fantastic project you completed, the cost reduction measures you created, or the efficiency improvements you made. Pull specific data that supports your case and be sure to include numbers that show improvements you created.
Provide direction on what skills you want to develop.
If you feel like your performance is weak in a particular area of the review, don't hide it. This is your chance to show your self-awareness and ask for help. Write out an action plan for how you would like to develop these skills further. You don't have to say you're incompetent in an area if you aren't, but acknowledge your weaknesses so your supervisor can support your growth. Be sure to keep your impostor syndrome in check during this part of the self-evaluation. It's likely you'll be more critical of yourself than a supervisor might be.
The review process is an excellent time to advocate for your next raise or promotion if you prepare right. Starting with a self-evaluation gives you the chance to advocate for yourself before the review even takes place and your supervisor has made up their mind on what you deserve.
Are self-evaluations part of your office's performance review process or do you plan to ask for one in the future? Tell me in the comments below!
Jackie Follmuth received her Master of Public Administration degree from Texas Tech University and earned her Bachelors in Public Management & Policy at the University of Arizona. Jackie has a passion for leadership, management, digital marketing, and swimming education. She previously served as Bossed Up's Digital Director, but has since moved on to be a data specialist for a non-profit in her hometown.


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New Filtration Technology Keeps Cooling Tower Water Clean
Related Articles
- New Filtration Technology Keeps Cooling Tower Water Clean. // Heating/Piping/Air Conditioning Engineering;May2004, Vol. 76 Issue 5, p88
Provides information on new filtration technology from Orival Inc. that can keep cooling tower water clean as of May 31, 2004. Characteristics of Orival filters; Advantages of using Orival filters.
- Partially Restricted Filter Driers. Tomczyk, John // Air Conditioning, Heating & Refrigeration News;3/4/2013, Vol. 248 Issue 9, p18
The article focuses on the filter driers located in the refrigeration system's liquid line. A filter drier is referred as a liquid-line restriction because it can become restricted from moisture, sludge, dirt or oil. It discusses the cause for restricted liquid lines. It also describes several...
- New Filtration Technology Keeps Cooling Tower Water Clean. // Process Cooling & Equipment;Jan2007, p23
The article reports on filtration technology for cooling towers in the U.S. It states that every cooling tower has its unique dirt conditions, space constraints and other special characteristics. Filtration systems must take it into account to maintain a particle-free water in the cooling tower....
- Rx for Cooling Towers. Delenikos, Randy // Power Engineering;Nov2006, Vol. 110 Issue 11, p68
The article offers information on managing and maintaining evaporative cooling towers. Criteria for determining the cost efficiency of filtration equipment is presented. Factors to consider in choosing filtration system are also provided. Approaches to control solid contaminants in evaporative...
- FILTRATION TRENDS. // Process Cooling & Equipment;Jul/Aug2010, p7
The article focuses on the functionality of filters from Orival Water Filters to remove a wide range of dirt down to micron size of any specific gravity for cooling towers.
- New Filtration Technology Keeps Cooling Tower Water Clean. // Heating/Piping/Air Conditioning Engineering;Nov2015, Vol. 87 Issue 11, p11
The article provides information on the filtration technology used by Orival filters in keeping cooling tower water clean.
- Cooling Towers Loom Over Expo Crowd. // Air Conditioning, Heating & Refrigeration News;2/16/2004, Vol. 221 Issue 7, p40
Reports on the exhibit of cooling towers at the 2004 air conditioning, heating and refrigeration exposition in Anaheim, California. American Cooling Tower Inc.; Baltimore Aircoil Co.; Delta Cooling Towers; Great Lakes Fluid/Air.
- FYI…. Harris, Angela D. // Air Conditioning, Heating & Refrigeration News;9/19/2005, Vol. 226 Issue 3, p1
Reports developments in heating and ventilation industry. Price increase on cooling towers, closed-circuit coolers, replacement parts and freight for products manufactured in North America announced by Evapco Inc; Appointment of George E. Moore to the North American key account manager position...
- Parasitic Loads. Pearson, Andy // ASHRAE Journal;Sep2012, Vol. 54 Issue 9, p90
The seventh in a series of articles that explores refrigeration and heat pump concepts is presented. This article discusses a parasitic load for cooling systems which means an additional demand on resources that could be smaller or need not be there. The two types of parasitic loss, deliberate...


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Invisalign Jerome, IL
Daydreaming about Invisalign in Jerome, IL? For people with a crooked or misaligned smile, this system is an unobtrusive and fast way to straighten teeth. Your first question may be, "Where is there an Invisalign dentist near me?" Fortunately, Renken Dentistry is located conveniently nearby in Springfield. Our office hours are Monday-Thursday 7 AM – 6 PM, so you can plan an appointment before or after work, school, and other activities. An Invisalign doctor in our office can determine whether your teeth are a good fit for this system.
Your Invisalign Doctor
Invisalign is a system of clear aligner trays that get changed out progressively. Over the course of about a year, your teeth are moved closer and closer to the desired position. At the end of the year, you have beautiful, straight teeth! Invisalign has helped many Jerome, IL patients gain confidence in their smile. While straightening teeth and correcting gaps and misalignment, the clear aligner trays are natural and unobtrusive. People will be barely able to tell you are wearing them! Unlike clunky metal braces, Invisalign are clear and blend in with your teeth. The clear aligner trays are removed to eat, drink, brush, and floss, so you can take it out when having dinner with friends or for special occasions like a wedding. In general, the trays should be worn at least 21 hours a day, which is why we recommend this treatment for teenagers and adults.
For many people who want straighter teeth without the look of traditional braces, Invisalign is a faster and more natural-looking option. You might be searching "Invisalign dentist near me" online right now! If you want Invisalign in Jerome, IL, all you have to do is make an appointment with your Renken dentist. We also offer cosmetic services, such as teeth whitening, for patients looking to perfect their smile. Call (217) 483-7177 to schedule your free Invisalign consultation today.


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Ematic EMW3401 Full Motion Universal Wall Mount for 10" to 49" TVs w/ Tilt and Swivel Articulating Arm
The Ematic 10 to 49 TV Wall Mount Kit safely mount your TV to your wall. Completely adjustable for optimal viewing: +15° / -5° tilt and 180° pan/swivel. Includes all mounting hardware.
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Welcome to our website! As we have the ability to list over one million items on our website (our selection changes all of the time), it is not feasible for a company our size to record and playback the descriptions on every item on our website. However, if you have a disability we are here to help you. Please call our disability services phone line at 800-927-0543 during regular business hours and one of our kind and friendly personal shoppers will help you navigate through our website, help conduct advanced searches, help you choose the item you are looking for with the specifications you are seeking, read you the specifications of any item and consult with you about the products themselves. There is no charge for the help of this personal shopper for anyone with a disability. Finally, your personal shopper will explain our Privacy Policy and Terms of Service, and help you place an order if you so desire.
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In the current environment, 10% growth among the IPA 100 firms continues to be a metric that is the envy of their peers. Single-minded focus on growing industry niches and deepening expertise are the hallmarks of those firms excelling. Wilmington, Del.-based The Siegfried Group, the fastest-growing IPA 100 firm, has made the most of an alternative business model.
The firm's resourcing practice is unique. Firm employees are placed with clients to help them with "strategically significant" work, so the firm's rates of growth and decline are magnified depending on which way the economic growth curve is pointing. According to the AICPA, any firm that is predominantly owned by licensed CPAs is considered a CPA firm.
The Siegfried Group made its debut in 2005 at $40 million. By 2007, they grew to $86 million. In 2009, Siegfried dropped by more than half to $38.9 million. Two years later, Siegfried regained ground to come in at No. 48, with $65.4 million in net revenues.
The remaining top 10, including two ties, are: New York-based Raich Ende Malter & Co. and Lancaster-Pa.-based Reinsel Kuntz Lesher, both at 18.2% growth; San Ramon, Calif.-based Armanino McKenna at 17.6%; Fort Worth, Texas-based Whitley Penn at 17.2%; Portland, Maine-based BerryDunn at 14.8%; Jericho, N.Y.-based Grassi & Co. at 12.0%; Providence, R.I.-based Kahn, Litwin, Renza & Co., at 11.7%; Roseland, N.J.-based Rothstein Kass at 11.3%; and San Francisco-based Novogradac & Co. and Rockville, Md.-based Aronson, both experiencing 10.0% growth.
See the entire IPA Top 100.


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Gretawire has posted that Governor Sarah Palin will be a guest of "On The Record" tonight at 10:00 p.m. Eastern on the FOX News channel. The following information is provided:
Former governor Sarah Palin on the latest from the campaign trail!
Posted by Jackie Siciliano on August 21, 2012
Gretawire has posted that Governor Sarah Palin will be a guest of "On The Record" tonight at 10:00 p.m. Eastern on the FOX News channel. The following information is provided:
Former governor Sarah Palin on the latest from the campaign trail!
Posted in Uncategorized | Tagged: 2012, Elections, Fox News, Greta Van Susteren, Sarah Palin | Leave a Comment »
Posted by Dr. Fay on August 21, 2012
Video retrieved from NBCNetworkShows.
The full version of the video can be viewed here.
If anything, Episode 2 of 'Stars Earn Stripes' was even more action-packed and suspense-filled than Episode 1. A close tie involving a fraction of a minute (a difference of 17 seconds) between the two slower teams resulted in a shootout that eliminated Terry Crews and his operative from the competition. The remaining competitors will compete again on next week's show.
Before their second assignment, the celebrities had to go through another session of basic training. Todd Palin remarked, "You can never have enough training. The more training the better."
We got to watch Todd in target practice, when he was hitting dead center. It looked like practice paid off. Operative Cortes said in a vignette that accompanied the target practice scene: "After speaking with Todd and learning how his son was serving in Afghanistan, and how he hopes to make his son proud of him, I can see it in his eyes, man. I know he's here for something much bigger than just himself. That's going to keep us alive in this competition."
After training, Todd's squad was the first to compete. He and Leila had to drop from a helicopter onto the roof of an 8-story building, eliminate a fuel depot, rappel down the building into a truck, and then take out 10 more targets before jumping into a truck that drove over a fuel line that exploded behind them.
Laila Ali had to overcome her fear while rappelling down the building. Todd encouraged her as they descended: ""Good job, you got it! … Good job, Leila!"
Todd took out the first 3 targets with one shot each. Chris Kyle remarked, "Todd Palin, he's just a natural outdoorsman, shooter, I mean, Todd knocked it out of the park. "
As the squad was jumping into a truck and driving away, Operative Cortes said, " I think Todd and I – we represent the everyday guy. We weren't born with certain physical attributes, but what we are are people who care, and we care enough to take risks."
Posted in Uncategorized | Tagged: Aila Ali, JW Cortes, military, NBC, Stars Earn Stripes, Todd Palin | Leave a Comment »


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These People Eat, Sleep, And Breathe The Red, White, And Blue
America is a wondrous place full of freedom and fireworks and bald eagles. She deserves to be celebrated in the loudest, most epic way possible. The fourth of July is America's birthday, and these people know how to show her a good time.
You wish you could get on this level. Keep reading for a mustache that's more American than apple pie, a woman who's figured out how to sleep and get snacks at the same time, and a famous face who just terminated the heck out of the American citizenship test.
Freedom Is All Around Us
Photo Credit: snow-crash-1794 / Reddit
This is the correct way to decorate for the fourth of July. Go big or go home. Just a heads up, this is one of the classiest pictures you will see on this list.
From here on out, things get spicy. But for now, enjoy this nicely cut lawn and idyllic American house.
This Flag Takes The Cake
Photo Credit: dantissimo27 / Reddit
What's better than an American flag? An American flag you can eat, of course. It looks like someone spent a lot of time baking, cutting, and icing all of those layers.
Now we just have to figure out how to get some stars in there. Maybe some white sprinkles stirred into the blue bit of cake?
What Freedom Looks Like
Photo Credit: NarcolepticGamer / Reddit
Around mid-June, displays like this one start popping up in supermarkets all across America.
This one looks like it took some real creativity and advanced planning. I am thoroughly impressed. I hope whoever did this gets paid more than minimum wage. Keep reading for a man who wears his patriotism on his… chest.
As American As Pepperoni Pizza
Photo Credit: Ryandie112 / Reddit
Ok, so pizza is technically Italian, but Americans made it great, so now we can claim it as our own.
This actually looks super delicious. I don't care how unevenly distributed those pieces of pepperoni are— 10/10, would still eat. Pepperoni pizza is the backbone of America.
Sail Over To America
Photo Credit: KeithSkud / Reddit
Flags are nice, but a handcrafted red and white beer can sailboat is nicer. This is so American I'm half expecting it to start singing the national anthem at any moment.
It does look sort of sharp, though. Like it could cut through communism with a single swipe.
A Hairy Situation
Photo Credit: Imgur
Now here's one way to show your support for the world's greatest country— shave and American flag into your chest hair.
You can't see this guy's face, but I'd bet a million dollars he's chanting, "USA! USA!" What a magical place we live in. Read on for a guy who saw this guy's chest hair, and raised him an epic mustache.
Land Of The Free, Home Of The Brave
Photo Credit: jaycrew / Reddit
I think this is what every other country thinks America looks like all the time. 'Murica at it's finest.
I may be mistaken, but I think he is trying to retrieve a box of Diet Pepsi. The irony is almost too much. Someone, please help him— he's fallen, and he can't get up.
The Most American Fire Hydrant
Photo Credit: bacon_over_hoes / Reddit
Somebody thought this fire hydrant didn't look quite free enough— so they gave it a makeover.
I think it's probably full of domestic beer. Let's tap it and find out. I bet it puts out 1776 gallons a minute. That's a history joke. I hope you liked it.
An Intricate Dye Job
Photo Credit: Faustin / Reddit
As tacky as this is, I still think it's pretty impressive. You have to be pretty precise to get in all those stars and stripes.
This guy is American through and through. I am proud to call him a compatriot. He had the nerve to do what most of us couldn't even dream of.
What Would America Be Without BBQ?
Photo Credit: Imgur
I might steal this idea for my own fourth of July BBQ. I don't know about you, but I think it's brilliant.
Only, I think I'd do it bigger. We're going to need more than four hamburgers. It's time to bring out the big smoker.
As Wide As It Is Free
Photo Credit: bam_nam / Reddit
So, these chairs actually exist. People in America are so… well fed that they actually need special, enlarged office chairs.
This is not an office loveseat. It is a chair for a single proud American. Keep reading for the most American wedding you could possibly imagine.
A Beer In The Hand Is Worth Two In The Hoodie
Photo Credit: Imgur
If you don't live in a country where they sell hoodies with beer pockets, you're living in the wrong country.
What could be better than enjoying a hands-free beer while your clothing keeps it at perfect beer temperature? The American flag on this hoodie is just the icing on the cake.
Wait 'Till You See What Kind Of Car It Is
Photo Credit: Imgur
That's right. It's a Liberty. We don't just love freedom here in America— we drive freedom.
And have you ever seen anything more free than this red, white, and blue SUV? I didn't think so. God bless whoever owns this car. God bless America.
Till Mud Do Us Part
Photo Credit: buttcheeks420 / Reddit
If you want to say, "I do" in the most American way possible, grab your lady, grab a monster truck, and grab an officiant wearing a camo vest.
After you say your vows, you can jump in the mud and bless your union by literally becoming one with the land.
Too Free For Sleeves
Photo Credit: ICantDoMathRight / Reddit
Think about this for a second— somebody actually designed this shirt and then sold the design, and the shirt got printed, and then somebody decided to buy it. That's a lot of steps.
This shirt had to get past all of those steps to come into existence. Who allowed this to happen?
We're All About Innovation Here In America
Photo Credit: connr-crmaclb / Reddit
This passenger on an American Airlines flight came up with a genius idea. That's the kind of innovation that America was built on.
I am so proud of her. I hope she got lots of snacks and drinks. Keep reading for a food item that's even more American than apple pie.
The Day He Received His 'Murican Citizenship
Photo Credit: PM_ME_GECKOS / Reddit
Arnold may not sound American, but in this photo, he's as American as they come. Those guns are definitely covered under the second amendment.
Arnie is exercising his right to bare arms, and I am definitely not mad about it. He looks so excited in this picture.
This Is What America Is All About
Photo Credit: Elementhunter256 / Reddit
The only thing that could make this more American would be a full red, white, and blue fireworks display after the bird was rescued.
There probably was one. It looks like the guy in that picture would make sure that his heroism was celebrated the right way.
50 States Of Quality Pork Chop
Photo Credit: SmartHercules / Reddit
Have you ever eaten your way through all 50 states? I don't mean getting cheese from Wisconsin and peaches from Georgia and whatever food Minnesota is famous for from Minnesota.
This is how you eat through all of the states the lazy way— which we all know is the American way.
Beer And Kegs And A Tank, Oh My
Photo Credit: sjcokc / Reddit
People look at America, and they criticize us for our obesity rates and our subpar intellect and our president… but look at this marvel of liquid courage and human innovation.
How could anybody look at this and think a bad thing about us? They better not say a bad thing about us, because we have a beer tank, and we're not afraid to use it.


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Course summary
TEF Silver
Glyndwr University, Wrexham has opted into the TEF and received a Silver award.
Developing key skills and sound knowledge for a successful career in aircraft industries, as well as in a variety of modern engineering sectors, these courses benefit from strong industrial links and is designed to fulfil industries' requirements. The courses are focused on design. You'll develop a full understanding of engineering design concepts and the engineering design process. You can explore radical new aeronautical and aerospace concepts and complement this with expertise in mechanical engineering to produce designs. In addition to specialist knowledge and skills in aeronautical engineering, this course also emphasize transferable knowledge and skills to equip you for a broader job market. The first part of the course will introduce you to the fundamentals of mechanical and electrical science, the mechanics of solids and machines and computer-aided design. Then you'll develop more advanced knowledge, looking at aerodynamics, engineering dynamics, engineering design, structures and vibration analysis, fluid mechanics, thermodynamics, propulsion, aircraft design, aircraft stability, and control. You'll be trained to use variety of computer-aided design tools, including industry-highly-required Finite Element Analysis (FEA) and Computational Fluid Dynamics (CFD) tools. Also, honing your business skills are a key focus throughout the course. You can also choose to study this course as a foundation year: Aeronautical and Mechanical Engineering (with foundation year)
Course details
YEAR 1 (LEVEL 4) Year 1 will develop an understanding of the fundamental concepts, principles and theories in engineering. Acquire basic mathematic skills related to engineering and design problems. Use CAD for engineering design. Competence of working safely in engineering laboratories and workshops, and being able to conduct laboratory procedures, measurement and workshop practices under the guidance of a tutor. MODULES Mechanical Science Electrical Science Materials and Manufacturing Engineering Mathematics Engineering Design and Practice Aircraft Technology YEAR 2 (LEVEL 5) Level 5 will build on the knowledge, concepts and skills acquired at level 4 in addition to more specialist knowledge, skills in engineering design and analysis. More in-depth in theories in mechanics, thermodynamics, propulsion, flight dynamics, avionics, control systems, structures and finite element analysis, etc. Develop an understanding of business and research methods. MODULES Business and Research Development Thermo-fluid and Propulsion Further Engineering Mathematics Engineering and Mechanism Dynamics and Engineering Design Structures Analysis Avionics, Flight Dynamics and Control YEAR 3 (LEVEL 6) At level 6 students will acquire a critical understanding and application of the higher level concepts, principles and theories in engineering as well as a critical understanding and explanation of advanced topics in structural vibration, thermodynamics, aerodynamics, flight stability and control, and aircraft design. Use knowledge and skills acquired to do an individual project. MODULES Dissertation (Honours) Engineering Modelling and Simulation Aerodynamics Structural Vibration Analysis Optional Aircraft Stability, Control and Design Advanced Thermo-fluid and Turbomachinery Composite Materials The information listed in this section is an overview of the academic content of the programme that will take the form of either core or option modules. Modules are designated as core or option in accordance with professional body requirements and internal academic framework review, so may be subject to change.
Assessment method
A broad range of assessment methods are used; these include phase tests, written assignments, practical work on computers, portfolio of work, logbooks, presentations and laboratory work case studies and CAD. A combination of this work may form part of your assessment, alongside time-constrained exams. Each module is assessed by a variety of methods, enabling students to display their full potential. A project dissertation will form one of the final parts of your assessment. TEACHING AND LEARNING Teaching methods include lectures, laboratory sessions, student-led seminars and guided research. Independent learning is an important aspect of all modules, as it enables students to develop both their subject specific and key skills. Independent learning is promoted through guided study or feedbacks given to students. Wrexham Glyndŵr University is committed to supporting our students to maximise their academic potential. We offer workshops and support sessions in areas such as academic writing, effective note-making and preparing for assignments. Students can book appointments with academic skills tutors dedicated to helping deal with the practicalities of university work. Our website (student support section) has more information on the help available.
How to apply
Application deadlines
If your application is completed by the following date, it's guaranteed to be considered:
15 January*If you apply after this deadline, universities or colleges don't have to consider your application if they've filled their spaces, so the sooner you apply, the better!
Application codes
You will need these codes when you add a choice to your application.
|Course code
|Institution code
|Campus name
|Campus code
Points of entry
The following entry points are available for this course:
- Year 1
- Year 2
- Year 3
International applicants
If you require a Tier 4 visa to study in the UK, please apply through Centurus at https://centurusone.com/apply/1111.
Entry requirements
Qualification requirements
|Further information
|UCAS Tariff
|112 points
|Including Level 3 Maths and/or a related science.
|A level
|Pearson BTEC Level 3 National Extended Diploma (first teaching from September 2016)
|Access to HE Diploma
|112 UCAS Tariff points
|Scottish Higher
|112 UCAS Tariff points
|Accepted alongside A-Levels as part of overall 112 UCAS Tariff requirement.
|Scottish Advanced Higher
|112 UCAS Tariff points
|International Baccalaureate Diploma Programme
|112 UCAS Tariff points from International Baccalaureate Certificates
|Welsh Baccalaureate - Advanced Skills Challenge Certificate (first teaching September 2015)
|Accepted as part of overall 112 UCAS Tariff point requirement.
|Extended Project
|Accepted as part of overall 112 UCAS Tariff requirement.
|Leaving Certificate - Higher Level (Ireland) (first awarded in 2017)
|112 UCAS Tariff points
|Leaving Certificate - Ordinary Level (Ireland) (first awarded in 2017)
|Accepted alongside Irish Leaving Certificate Higher Level as part of overall 112 UCAS Tariff requirement.
|Cambridge International Pre-U Certificate - Principal
|112 UCAS Tariff points
Wrexham Glyndwr University takes into account a variety of qualifications and experience when considering applications to our programmes. If you are unsure if the qualifications you currently hold will be accepted for entry, or if you're not sure you'll achieve the required UCAS Tariff points, please contact us at [email protected] for further advice and guidance.
Fees and funding
Tuition fees
|Year 1
|Year 1
|Northern Ireland
|Year 1
|Year 1
|Year 1
|Channel Islands
|Year 1
|Year 1
*This is a provisional fee and subject to change.
Additional fee information
Provider information
Glyndwr University, Wrexham
Plas Coch
Mold Road
Course contact detailsVisit our course page
Admissions and Enquiries
01978 293439


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The Parkland shooting from a year ago continues to affect the victims from that day. Recently it was reported that Sydney Aiello, a survivor of Parkland, took her own life as a result of Post traumatic stress form the shooting. … Continue reading
Category Archives: Terrorism
Since my last post I have purposely sat back and watched to see what the reaction would be to what has happened over the course of the last week. I have witnessed most of my friends support my position in … Continue reading
I don't know how to follow up last night's post.. The emotions are still raw in me and I don't know where to go from here. I usually post about sports as it is my crutch, to keep me from … Continue reading
This is going to be long-winded, so if you don't have the time… save it for later.. People that know me understand that I rarely bring up politics. I prefer to keep my opinions and beliefs to myself. The reason … Continue reading
Maybe I have a reputation of staying in my comfort zone, maybe I am one to be non-confrontational or non-controversial. No more… Today's events have pissed me off, today's events have taken me over the brink. Isis has attacked Paris. … Continue reading


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Peter Trueb calculated pi to 22.4 trillion digits
Tag Archives: math
Math & Science…A New Context Isn't a New Problem: Strategies to Help Students Transfer Skills
Author: Tasha Richardson, Teacher – TDSB, @tadric3EM
As a physics teacher, I have always been very interested in students' abilities to apply previously learned mathematical skills in the classroom. Continue reading
Test Your Knowledge With Our Pi Day Quiz – World Science Festival
Saturday, March 14 was the unofficial math holiday known as Pi Day. Celebrated throughout geekdom, Pi Day is so crowned because the first three digits of pi (3, 1, 4) are like the numeric representation for March 14 (3/14). This year it's even more special because it will be 3/14/15, as in the first five digits of pi (3.1415). Maybe you knew all that. But what else do you know?
Before pi, there was this simple Latin phrase to express what pi represents: "Quantitas in quam cum multiflicetur diameter, proveniet circumferencia." OK, not as simple as pi, sure. But don't worry—no knowledge of Latin is needed for our fun, little quiz.
Still, while it may not be easy as pie (or pi?), our quiz will definitely test your knowledge of pi and culture—and it's way less caloric than those round things with those deliciously buttery crusts.
By: Erica Rowell
Quiz: 10 Trivia Questions About Pi
Feeling smart? Like trivia? Love pi? Let's go.
Go the to the WSF link below to try the quiz.
via Test Your Knowledge With Our Pi Day Quiz – World Science Festival.


text: Scroll has been a trusted supplier of content to the public sector since 2004, with 250 content experts across the UK. We offer all cloud services for content, including design, strategy, training. We played a significant role in designing content for GOV.UK and services that passed the Digital Service Standard.


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Comic-Con Tips for First Time Attendees
San Diego Comic Con (SDCC) is next week and we can't wait! We are now in the middle of con season, so it seems like cons are happening every weekend. We wanted to share some comic-con tips for first time attendees, and really just anyone going to a con. These are great tips for any […]Continue Reading


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Your home should reflect your own personal style and tastes, but also give you the functionality you need. From choosing the decor to picking out the furniture, every detail in every room in your home, no matter how small, can add to or take away from that.
If you are working on a new build or planning renovations for your home, come to Five Lakes Cabinetry and Woodworking. We are your local woodworking specialists in Birmingham that will give your home the unique, personalized feel you're looking for.
If you are working on a new build or planning renovations for your home, come to Five Lakes Cabinetry and Woodworking. We are your local woodworking specialists in Birmingham that will give your home the unique, personalized feel you're looking for.
Expert Woodworking Service in Birmingham
Our team of expert woodworkers has the skills, experience and expertise to make any vision come to life for your home. We also have an in-house architect and interior designer who lend their own expertise on projects as needed. With a diverse team, we are prepared to help turn your house into a home.
Custom woodworking shows your need for individuality as well as your dedication to making your home completely your own. We work with every one of our clients through every step of the process, from understanding your unique tastes and style to completing the project. When we're done, we know that you will love the end result for many years to come.
No matter your home's decor style, our beautiful work will blend in perfectly. For example, a shiplapped wall can give your living space a comforting but also bold feel. Wooden ceiling beams give an open floor plan an element that brings everything together. At Five Lakes Cabinetry and Woodworking, we are ready to complete these projects and more for your home.
Custom Solutions for Every Room
Custom woodworking for your Birmingham, Michigan, home looks incredible in any room. From creating detailed shelves for a den or library to custom solutions for closets and more, no matter your goal for the project, Five Lakes Cabinetry and Woodworking will make it happen. We have confidence in our work and we know you will love the end result.
You won't find the same level of quality from other woodworkers in the area. We use top-quality materials and our expertise to complete any woodworking project that you have in mind. Whether you have a specific vision or need some help finding the right design, our years of experience will go to work in producing a beautiful finished product.
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These two clips are so surreal as to defy explanation. Imagine someone explaining to your kids that Osama Bin Laden and Al Qaeda were the good guys, and you'll have some sense of what it's like to hear a woman lionizing the Red Shirts to a descendant of black South Carolina.
Some history on the Red Shirts here. I think the basic problem is that, when your lineage is all you have, when kinship is the only thing that defines you, how do you say, "My grandparents were not cheated. They were not righteous. They were terrorists and sore losers, who deserved to lose." And how do you say that knowing that, at the same time, they may have been loving mothers and fathers. That they were not monsters.
I don't know. But that's how it happens.
H/T Kevin Levin.
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Ta-Nehisi Coates is a national correspondent for The Atlantic, where he writes about culture, politics, and social issues. He is the author of The Beautiful Struggle, Between the World and Me, and We Were Eight Years in Power.


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I've spent the past few days fuming at Hillary Clinton because her primary trash talk has fueled new ads by John McCain. The most grievous example being her assertion that she and McCain were ready to be President while Barack Obama was merely a speech maker.
I approached tonight's speech by Senator Clinton at the Democratic Convention, with limited expectation. I was fully prepared for a self serving, half hearted endorsement of Obama. I'm glad to say I was wrong. There was not much Hillary could have done better tonight.
Of course the Republicans have already issued a statement saying that no where in Hillary's speech did she say that Barack is ready to be President. Technically, this is true. I would have been happier if Hillary had explicitly repudiated McCain's latest series of ads and if she had said without any doubt that Barack Obama is ready on day one to be President of the United States. However, upon further reflection, I think that had she done THAT much of an about-face, she would have lost credibility. It was almost more effective for her to say that regardless of Obama's preparedness for office, the alternative of McCain is no alternative at all.
By comparing her husband's accomplishments with Democrats by his side to the anticipated accomplishments of an Obama administration, she basically passed the proverbial torch to Obama in much the same way that Kennedy did the night before.
So, my hat is off to Hillary tonight. She did what she needed to do and did it convincingly. Perhaps she put it best with the plain spoken words that may become a new campaign mantra:
"No way, no how, no McCain!"


text: This one could well have been termed as a dance soundtrack on the lines of ABCD! With the core of the music comprising of several fast paced dance outings, Nawabzaade is a film primarily starring newcomers with quite some energy and enthusiasm on display. This is complimented well by the team of composers, lyricists and singers who put together half a dozen songs for the album.


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From whence did you come my daughter dear?
You fell from heaven through the stardust
Into my world awaiting God's gift.
Where did you get those precious little ears?
A meadow lark song filled morning's first light
To welcome you to God's exquisite creation.
From whence did you get your emerald eyes?
A little piece of a gorgeous rainbow
Just slipped into your smiling face.
Where did you get those soft arms and hands?
Love grew into gentle hooks and limbs
To touch a world that needed God's care.
From whence your lovely smiles full of bliss?
A thousand angels smiled on you
As you sped through the cosmos to me.
Where did you get your charming roseate cheeks?
The sun shown brightly through fluffy clouds
As you gently landed on the earth.
How did all this beauty become you?
The heavens smiled down upon me
And bestowed a gift-you my daughter.
Poem Of Love From Father To Daughter
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My Daughter
Published: December 2007
From whence did you come my daughter dear?