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Scoping review of acute stroke care management and rehabilitation in low and middle-income countries
Stroke is a major public health concern, affecting millions of people worldwide. Care of the condition however, remain inconsistent in developing countries. The purpose of this scoping review was to document evidence of stroke care and service delivery in low and middle-income countries to better inform development of a context-fit stroke model of care.
An interpretative scoping literature review based on Arksey and O’Malley’s five-stage-process was executed. The following databases searched for literature published between 2010 and 2017; Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, Cumulative Index to Nursing and Allied Health Literature (CINNAHL), Academic Search Complete, and Google Scholar. Single combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, low and middle-income countries.
A total of 177 references were identified. Twenty of them, published between 2010 and 2017, were included in the review. Applying the Donebedian Model of quality of care, seven dimensions of stroke-care structure, six dimensions of stroke care processes, and six dimensions of stroke care outcomes were identified. Structure of stroke care included availability of a stroke unit, an accident and emergency department, a multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. Stroke care processes that emerged were assessment and diagnosis, referrals, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies. Stroke-care outcomes included quality of stroke-care practice, functional independence level, length of stay, mortality, living at home, and institutionalization.
There is lack of uniformity in the way stroke care is advanced in low and middle-income countries. This is reflected in the unsatisfactory stroke care structure, processes, and outcomes. There is a need for stroke care settings to adopt quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke. Stroke Units and Recombinant Tissue Plasminogen Activator (rtPA) administration could be considered as both a structural and process necessity towards improvement of outcomes of patients with stroke in the LMICs.
KeywordsAcute stroke Stroke care structure Stroke care process Stroke care outcomes Low and middle income-countries
Cumulative Index to Nursing and Allied Health Literature
Low- and Middle-Income Countries
Length of Hospital Stay
Medical subject headings
Magnetic Resonance Imaging
Modified Rankin scale
Recombinant Tissue Plasminogen Activator
Structures, Processes, and Outcomes
Stroke is a major public health concern, both debilitating and deadly to millions of people worldwide each year . Stroke frequently leads to loss of functional independence from physical and cognitive dysfunction. While stroke is stressful, efforts toward better outcomes, such as limiting the disability, more effective means of coping with loss, adaptation to change, and temporal ordering of coping processes could help patients recover to their highest possible functional level . To achieve these outcomes, high quality care is needed. The quality of patient care can be conceptualized using a model, such as the one developed by Donebedian.
Donabedian model (DM): the conceptual framework
Known as the most comprehensive model for assessing quality of health care , as presented in 1966, the model has three distinct aspects to health care quality: structures, processes, and outcomes (SPO) . Accordingly, Structures of health care are defined as the physical and organizational aspects of care settings, for example, facilities, equipment, personnel, operational, and financial processes supporting medical care. Processes in patient care include resources, mechanisms provided by the health care structures to carry out patient-care activities that promote recovery, functional restoration, survival, and patient satisfaction (the Outcomes) .
In addition to developing the methodology for measuring structures, processes, and outcomes, Donabedian made an equally important contribution by prioritizing governance and management. When supported by measurement methods, they could be the determining causes of the effectiveness and efficiency of health services . Related to quality of care, Donabedian said “systems … are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success.” . This is in sharp contrast to the ideologies of other researchers who advocated universal coverage or claimed that physicians’ clinical and financial autonomy was a precondition for the quality of care .
The relationships between structures, processes, and outcomes were effectively presented in a South African study which assessed quality of integrated chronic disease, among patients and operational managers. The study found that structure-related construct was the availability of equipment, supply of critical medicines, and accessibility of chronic disease care. Those related to process were communication between the nurses and patients, attendance of the nurses to patients’ health needs, professional conduct of the nurses, nurses’ friendliness with patients, hospital referrals for patients, pre-packaging of medicines, physical examination of patients; and the time nurses spent with patients during consultation. Whereas, outcome-related construct included coherence of integrated chronic disease care, competence of nurses, and patients’ confidence in nurses .
Effective stroke care included assessment (completed within 48 h post stroke) , early mobilization to prevent or reduce complications such as infections, deep vein thromboses (DVT), and falls, and promote recovery , avoidance of urinary catheterization, leading to bladder infections , treatment of hypoxia, hyperglycemia, and suspected infections , and ongoing rehabilitation activities . Internationally, four acute-care intervention processes have been recommended by most stroke experts as the most effective front-line interventions. Those included care in a specialised stroke unit (SU), , thrombolytic therapy through tissue plasminogen activator (t-PA) for acute ischemic stroke (within 4.5 h of initial onset) [15, 16], aspirin therapy for acute ischaemic stroke (within 48 h) , and decompressive surgery (within 48 h)  to reduce stroke-related mortality and morbidity .
As highlighted, the most effective stroke-care service requires an organized setting such as SU care . However, where units do not exist, patients with stroke should be admitted to generic wards, staffed by a coordinated multidisciplinary team with special expertise in stroke care . In some settings in LMICs, such as those in Africa, multidisciplinary stroke-care teams are formed with non-specialist service providers, and in the absence of other equally important professionals, such as speech therapists . There is also a need for readily available radiological equipment to make the most accurate stroke diagnosis . Clinical methods predominate in resource-limited settings, , although Imam and Olorunfemi said such methods still need proper attention through a skills check . Accurate diagnosis of stroke related to site, size, and type still requires radiological methods.
It was recommended that appropriate systems of stroke care be established in LMICs to control the increasing death and disability associated with stroke [25, 26]. However, implementation of those systems is challenged by the absence of direct health policy support from the state or national level for stroke care .
Applying Arskey and O’Malley’s 2005 scoping review methodology , the purpose of this review was to systematically document the evidence of stroke care and rehabilitation service provision in LMICs that could inform the development of a more-effective contextual model of care for Malawians and ultimately an improvement in their quality of life.
“What are the components of acute stroke care and rehabilitation services by health personnel across the hospital stroke care continuum in LMIC?” This question was delineated to have “stroke care” AND “profession and setting” search terms.
Identifying relevant studies
According to Joanna Briggs Institute , in searching for articles to be included in a scoping review, the researcher undertakes a limited search of relevant databases, followed by analysis of text words from titles, abstracts, and index words. Therefore, this researcher performed an electronic database search that included Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, CINNAHL with full text, Academic Search Complete, and Google Scholar in January 2018. Search tools such as medical subject headings (MESH) and truncation to narrow or expand searches were utilized. Single and combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, and LMIC. This study included empirical English articles on stroke care, published between 2010 and 2017. Excluded studies were those from high-income countries using the World Bank definition  not within the defined range of publication time, and those covering participants under 18 years of age, per the United Nations Conventions of the Rights of the Child .
Selection of articles for inclusion
The researchers used a two-stage selection criterion  (Halas, Schultz, Rothney, Goertzen, Wener, and Katz, (2014). Initially, the researcher and team (GC, SM, FM HZ, and JA) screened the titles and reviewed them for relevance to acute stroke hospital and rehabilitation care from LMICs. Secondly, they screened the chosen articles’ abstracts with key sections of the introduction for answers to the research question and objectives, methods that included the article design, setting or context, key findings, and conclusions.
Data charting and collation
Scoping review articles (key details)
Author reference & recruitment context
Content of interest
Acute stroke presentation in hospitals
1. Albertino, Joana, Ana, et,al. nd
(Central hospitals, public hospitals, military hospitals & private clinics)
Retrospective & prospective
August 1, 2005 - July 31, 2006
Incidence, characteristics & short-term consequences of hospitalizations for stroke in Maputo and Mozambique
− 531 pts. (81.6%) with first stroke
− 601 cases (92.3%) confirmed by CT scan (83.4%) or necropsy (8.9%)
− 351 (58.4%) ischemic, 242 (40.3%) hemorrhagic, & 8 (1.3%) subarachnoid hemorrhage
-Ischemic events increased continuously with age (higher in men 45 to 64 yrs)
-Incidence of haemorrhagic stroke rose up to 74 years (yrs) of age; declining thereafter
− 15% of stroke events occurred in subjects aged 45 yrs. (??and higher/lower/exactly)
− 60% of pts. arrived at hospital on same day as symptom onset
-Most prevalent risk factor was hypertension (86.6 to 96.0%)
− 254 pts. (101 ischemic & 133 hemorrhagic stroke events) died during 28-day follow-up period
2. Yan, Li, Chen, et.al. 2016
17 included systematic reviews, observational cohort studies, meta-analyses, & case reports
-Risk factors for stroke
-Primary prevention of stroke
-Treatment of stroke during the acute stage
- History of hypertension, current smoking, diabetes mellitis, diet risk score, physical inactivity, alcohol intake, psychosocial stress & depression, & cardiac causes
-Guidelines for stroke diagnosis: patient history, physical examination, neurological examination & stroke scales, & diagnostic tests
- Primary preventive approaches: blood pressure control & promotion & maintenance of healthy lifestyle: not starting to smoke, & smoking cessation for smokers, no binge drinking, being physically active, & a healthy diet with adequate fruit & vegetable intake, reduced dietary trans-fat intake, & reduced sodium intake
-Intravenous thrombolysis approved as evidence-based treatment for acute ischemic stroke
-Mechanical thrombectomy in combination with pharmacological thrombolysis improved functional outcomes
- Pts. who received organized inpatient care in a SU were more likely to be alive, independent, & living at home 1 yr after stroke
-Secondary prevention of stroke: blood pressure control, antiplatelet & lipid-lowering therapy, homocysteine-lowering therapy, self-management, & family support
-Stroke rehabilitation: inpatient, home, & community-based programs, including physical, occupational, speech, & recreation therapies
- Availability of & access to rehabilitation services low in LMICs
-Factors for limited accessibility: poor physician knowledge of the role of rehabilitation; lack of rehabilitation components in the standard of care; long intervals from stroke onset to admission to rehabilitation; infrequent, unskilled, & short-lived provision of rehabilitation care; & inadequate public insurance or financial support for rehabilitation care
3. El Sayed, El Zahran & Tamim, 2014
Retrospective chart review
Pt characteristics & outcomes
Barriers to rt-PA utilization
Mean age of 71.9 yrs.; most pts. arrived by private transport (85.1%): weakness & loss of speech most common presenting signs (56.3%); 37.9% of pts. presented within 4.5 h of symptom onset
Nine pts. (10.3%) received rt-PA2 groups (rt-PA versus non rt-PA) with similar outcomes (mortality, symptomatic intracerebral hemorrhage, mRs scores, & residual deficit at hospital discharge)
rt-PA utilization was higher than expected
Delayed presentation barrier to rt-PA administration
4. Ashraf, Maneesh, Praveenkumar, et.al. 2015
Urban Hospital. India
Cross-sectional prospective study (Jan- Dec 2012
Factors contributing to delay in hospital arrival
Median delay = 12 h.
Distance from hospital, history of coronary artery disease, & presence of hemiplegia
5. Tirschwell, TGN, Ly, Van Ngo et.al. 2012
Urban Hospital (n = 1)
Prospective cohort study
Clinical predictors of 28-day mortality for admitted pts.
328 (43.5%) ischemic, 356 (48.5%) hemorrhagic
Risk factors: for ischemic stroke: atrial fibrillation, lower prevalence of hypertension, & previous history of stroke
Pts. with ischemic stroke less likely to have disturbed consciousness & speech disturbances, likely to have observed weakness, lower mean systolic & diastolic blood pressures, & higher mean total cholesterol levels
28-day crude mortality was 20.3% for pts. with ischemic stroke & 51.0%???; overall 37%
28-day predictor of poor outcome: hemorrhagic stroke type, worse pre-stroke Modified Rankin Scale (mRS), disturbed consciousness, absence of observed weakness at presentation, higher diastolic blood pressure, higher glucose levels, current tobacco smoking, & history of hypercholesterolemia
Strongest predictor: limited access to evidence-based standards of care due to limited local resources, & local evidence.
6. Robert & Zamzami, 2014
Incidence, prevalence type, risk factors of stroke; influence of age, gender differences, neuropsychiatric manifestations, health-related quality of life (QOL), LOS (LOS), medical care, & rehabilitation.
Low incidence & prevalence of stroke compared to Western countries
Ischaemic stroke predominated; Sub-Arachnoid Haemorrhage very rare
Important risk factors: hypertension, diabetes mellitus, coronary diseases, & smoking
Men at higher risk than women
Depression not frequent
Low QOL in pts. from Saudi Arabia compared with other countries
Age & functional status influenced HRQOL
Stroke severity, nature & other medical complications: predictors of LOS
Ministry of Health offers rehabilitation services; have one active stroke center
Research on stroke, establish SUs, increase public awareness, train health care providers, & increase the rehabilitation centers
7. Mohd Nordin, et.al. 2012
Urban Hospital. (n = 1)
Retrospective study from June to October 2010 for pts. 2006–2009
Individuals receiving rehabilitation services, their functional status on discharge
1. Ischemic stroke highest stroke subtype (66.4%)
2. No research on causes of ischemic stroke in Malaysians
3. 62.7% received rehabilitation during hospitalization: daily physiotherapy & occupational therapy
4. 3.0 days mean time from diagnosis of stroke to initiation of rehabilitation
5. Mean disability level at discharge = 3.5
6. Highest level of function at discharge: walking, then standing from sitting, followed by bed mobility & sitting up from supine (47, 25, 15, 12%)
7. > 50% of pts. had mRS score > 3 on discharge
8. Inadequate rehabilitation services for acute & sub-acute stroke survivors
8. Badachi, Mathew, Prabhu et.al. nd
Tertiary care center, South India
100 consecutive acute ischaemic events
Failure of pts. to recognize stroke symptoms, awareness of thrombolysis as a treatment modality, failure of patient’s relative to recognize stroke,failure of primary care physician to recognize stroke,transport delay, lack of neuroimaging & thrombolysis facility in 1st hospital of arrival, & non-affordability
1. Poor recognition of stroke symptoms by pts., relatives, & primary health care physicians; hence prehospital delay; attributed to lack of knowledge of stroke symptoms & hesitation to initiate treatment
2. No facilities for neuroimaging & thrombolysis for most tertiary hospital
3. Low utilization of thrombolytic therapy due to high cost
4. Inadequate ambulance services, especially in rural areas
5. Education efforts & awareness
6. Training of emergency physicians
7. Improve infrastructure in district hospitals
8. r-TPA should be available at subsidized rates
9. Neuroimaging facilities should be improved & made affordable
10. Uses of dedicated ambulance services
11. Stroke prevention programs on thrombosis needed
Stroke care structure
9. Ossou-Nguiet, Sossoumihen, Matali et.al. 2017
Urban Hospital (n = 1)
Inadequate availability of IV thrombolysis & mechanical thrombectomy interventions in SU.
1. Pt received IV thrombolysis only & died 24-h after admission
2. The unavailability of mechanical thrombectomy interventions
3. Few radiologists & MRI in sub -Saharan Africa
4. Need for enough medical personnel & appropriate equipment in SUs
10. Linda, Sebastiana, & Vanessa, 2009
Urban Hospital. (n = 1)
195 pts. (94 admitted before initiating SU, 101 thereafter)
Outcome of multidisciplinary stroke care in limited-resource settings
1. Inpatient mortality dropped from 33% (n = 31) to 16% (n = 16)
2. Referral to inpatient rehabilitation increased from 5% (n = 53) to 19% (n = 513) at discharge
3. Standardized investigation and evaluation of stroke admissions was better
4. Initiation of secondary prevention strategies was achieved
5. Prevention & treatment of complications of stroke was also achieved
6. Evaluation by multidisciplinary rehabilitation team was better achieved in SUs than in general ward
7. Staff education in stroke care & standardized discharge & rehabilitation planning was also better achieved in SU, compared to general wards
8. Involvement of relatives in SU was better achieved than in general wards
11. Gould, Asare, Akpalu et.al. nd
Review of local services for stroke care, assist with service plans, provide multidisciplinary education & training, & practical case-based problem solving
1. Need for frontline staff to improve delivery of stroke care
2. Establishment of Ghana’s first SU
12. Donia et.al. 2017
Urban Hospital. Egypt
Case report (Oct, 2016)
Administration of rTPA, dose, recommended administration time & availability of 2 in hospitals
Partial improvement during 3-month period after rTPA administration
Stroke Care Process
13. Leonard, Michael, George et.al. 2017
Urban hospitals. (n = 11)
A non-probabilistic purposive sampling technique used for recruitment
Nov 2015 - Apr 2016
11 participants (neurologists & physician specialists)
& medical officers (general physicians).
evaluating available acute stroke services
1. Availability of designated accident & emergency departments
2. Limited functional diagnostic & assessment services
3. Specific stroke clinical guidelines in all study hospitals
4. Few SUs available
5. No functional & standardised multidisciplinary team was evident
6. No provision of thrombolysis using tPA reported
7. Surgical procedures not conducted in any study hospital
8. Fewer/absence of stroke specialist
9. No direct health policy support from the state or national level for stroke care
14. Clarke, 2013
Review of stroke evidence
Effect of multidisciplinary stroke care & possible future direction
1. Pre-hospital & acute services improved recognition of stroke, established rapid specialist assessment resulting in more accurate diagnose & quality care
2. Thrombolysis can be safely administered up to six hours after witnessed stroke onset
3. Rehabilitation is key to stroke care
4. Rehabilitation interventions remain limited in some areas
5. Rehabilitation should commence as early as possible after stroke
6. SU team includes physiotherapists, occupational therapists, speech & language therapists, stroke physicians, nurses & healthcare assistants
7. Multidisciplinary team care resulted in long-term reductions in death, dependency & need for institutional care, facilitate earlier discharge to home increases likelihood pts. will regain independence in activities supporting daily living, & result in fewer pts. requiring long-term institutional care
8. Multidisciplinary team approach most effective way of providing high-quality stroke services
9. Need for early referral to clinical psychologists or psychiatrists to provide interventions when need arises
10. Co-ordinated multidisciplinary teamwork made improvements in quality of care in pts. with stroke
15. Al Khathaami, Algahtani, Alwabel, Alosherey, Kojan, & Aljumah et.al. 2011
Urban hospital, Saudi Arabia
Situation analysis study. Phone interviews.
Views & beliefs about current stroke care in the country, system deficiencies, attitude towards
t-PA use, logistics required to provide optimal stroke care, & the priorities needed for improvement
1. 71% of neurologists rated the care provided to stroke pts. at 6 or below on a scale between 1 (very poor) & 10 (best care)
2. Deficiencies in stroke care starting from prevention & education at the community level to post-stroke rehabilitation
3. Lack of thrombolysis program to the existing shortage of resources
4. Need for improvement
16. Ogungbo, Ushewokunze, Mendelow et.al. 2005 .
How to improve management of stroke
1. Population strategy by implementing Public awareness programs, Life style modification strategies
2. Introduction of stroke study groups & development of local guidelines among physicians
17. Rahil, Afshin, Anahid et.al. 2012
Letter to the Editor. Iran
Cost-effectiveness of rTPA in developing countries
1. No studies on cost-effectiveness of rTPA in developing countries
2. Studies done revealed rTPA as cost-effective in developed countries
3. Few rehabilitation centres in developing countries
Stroke care outcomes
18. Baatiema, Chan, Sav et.al. 2017 .
Hospitals across Africa
Systematic review using PRISMA
4 non experimental studies with 330 study participants between 2009 & 2016
Clinical efficacy of SUs
2. Less deaths (16%) Vs 33% prior SU
3. LOS 6.8 days compared to 5.1 days i general wards
4. Stroke referrals to inpatient rehab was higher than to general ward, (19% vs 5%)
5. Though not significant, patient access to CT brain scan was higher, 16%, in SU compared to 13% in the general medical ward
6. Improved pt. outcomes with use of thrombolytic therapy
7. Thrombolytic therapy can generate optimal patient outcomes in Africa
8. Imperative for policymakers to increase efforts to increase the use of thrombolytic therapy in hospital settings to reduce the current disproportionately high stroke burden in Africa
19. Rhoda A, Cunningham N, Azaria, 2015
Hospitals (n = 3) R, South Africa & TZ
-Time from stroke onset to admission
-in-patient physio & rehabilitation
Time interval stroke onset to admission 6.8, 0.3, & 1.2 days
LOS stay; 8.2, 7.38, & 12.19 for R, SA, & TZ respectively
40,68%, & 98% of pts. with stroke in R, TZ, & SA respectively, received physio-rehabilitation, 2 sessions/week in R & TZ, & 3 in SA
20. Olaleye & Lawal, 2017
(Urban hospital Nigeria)
Inpatient physio rehabilitation
1. Mean LOS = 16.2 days
2. Referral rate for PT high (75.8%)
3. Mean time from admission to referral for PT = 3 days
4. Majority (63.4%) of pts. referred utilized PT; mean number of PT sessions during in-patient care = 8.7
5. Utilization of in-patient PT significantly associated with reduced LOS
Collating, summarizing and reporting findings
To evaluate the evidence of stroke care in LMICs, the researchers summarized and categorized the data in line with the SPO model as the conceptual framework.
Evaluating the evidence on stroke care in the LMICs was facilitated by synthesizing findings of studies describing hospital acute stroke care and rehabilitation. The findings have been displayed, with their general characteristics such as the settings and locations. (Table 1). Various stroke care practices and service limitations have been noted based on conclusions and recommendation towards better practice by the authors. The Donabedian Model identified three primary themes of stroke care which are stroke care structure, process, and outcomes.
Descriptive presentation of results
The overall aim of this study was to determine the current evidence of stroke care and rehabilitation in LMICs. To achieve this aim, we first needed to understand current stroke care services in the countries that share similar evidence of stroke burden and economic characteristics. Studies from LMICs per the World Bank classification from 2009 and 2017 were included. In addition to noting the number of articles, we recorded general characteristics such as study settings. The findings were further illustrated in three key thematic areas based on the Donabedian model. The results are highlighted by the combination of texts, tables, and figures.
General characteristics of included articles
There was a total of 20 articles, published between 2009 and 2017. They were from different LMICc, with half  of the articles from Africa and the other half  from Asia. The design for most of the articles was a retrospective chart review (n = 8). Others were systematic reviews (n = 3), case report, situational analysis, and descriptive studies (n = 2), and 1 each for cross-sectional prospective study, literature review, descriptive studies, prospective follow-up. The focci of the articles was hospital care and rehabilitation services. The topics were categorized into SPO.
Stroke care structures
This scoping review had 19 dimensions of stroke care, thematically established from 11 articles [33, 34, 38, 40, 41, 42, 45, 46, 47, 48, 50]. Seven of them constituted the stroke care structure (Fig. 1). They were SU, accident and emergency department, multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. There were few or no SUs in any of the settings within the LMICs . The availability of designated accident and emergency departments that triage patients in LMICs, with specific clinical guidelines and functional and standardized multidisciplinary teams was associated with optimal stroke-care practice . There are, however, few specialist health care workforces for acute stroke care both in number and variety  to constitute multidisciplinary teams. This type of teamwork was reported as the most effective way of providing high-quality stroke services, even in less-resourced LMICs . There were no facilities for neuroimaging and thrombolysis for many tertiary hospitals, inadequate ambulance services especially in rural areas, limited educational efforts and awareness, inadequate training of emergency care physicians , unavailability of mechanical thrombectomy interventions, and few radiologists and MRI technology in sub -Saharan Africa . In those countries that had key radiological devices, such Computed Tomography (CT) scanners, there were effective diagnostic workups on patients with stroke. For example, 601 cases (92.3%) were confirmed either by CT scan (83.4%) or necropsy (8.9%) as ischemic or hemorrhagic stroke, or subarachnoid hemorrhages . Of note was that standardized investigation and evaluation of stroke assessment and admissions was much better after initiating multidisciplinary Stroke-Unit care, as established in some countries such as Ghana as a new development in the stroke care structure . There was also limitation in availability of key medical supplies, such as rtPA in most LMICs . There was poor physician knowledge of the role of rehabilitation; lack of rehabilitation components in the standard of care; a long interval from stroke onset to admission to rehabilitation; infrequent, unskilled, and short-lived provision of rehabilitation care; and inadequate public insurance or financial support for rehabilitation care .
In a related matter, countries such as Ghana had no direct health policy support from the state or national level for stroke care . Studies recommended that policymakers could facilitate the utilization of thrombolytic therapy in hospital settings to reduce the current disproportionately high stroke burden in Africa ; rtPA could, therefore, be made available at subsidized rates; neuroimaging facilities could be improved and made affordable, in addition to use of dedicated ambulance services , and stroke prevention programs on thrombosis should be initiated . Population strategy could focus on implementing public awareness programs, life-style modification strategies, the introduction of stroke study groups, development of local guidelines among physicians , upscaling rehabilitation services by training health care providers, and increasing the number of rehabilitation centers .
Some studies recommended a need for ministries of health and governments in LMICs to adopt and implement SUs for their reported impact on stroke outcomes [41, 42, 50]. For instance, the multidisciplinary teams afforded by SUs had been reported to have led to a drop in inpatient mortality, and increased referral to inpatient rehabilitation . Additionally, standardized investigation and evaluation of stroke admissions was much better after initiating multidisciplinary SU care; initiation of secondary prevention strategies, prevention and treatment of complications of stroke, evaluation by a multidisciplinary rehabilitation team, staff education in stroke care and standardized discharge and rehabilitation planning and involvement of relatives were more easily achieved in SUs than in general wards [42, 50]. Introduction of SUs was also associated with reduced LOS .
Stroke care process
Five studies highlighted the management of ischemic stroke using rtPA. Intravenous thrombolysis was approved as an evidence-based treatment for acute ischemic stroke in some settings within the LMICs . Although, there were no studies on the cost-effectiveness of rtPA in developing countries, studies in developed countries revealed that rtPA was cost-effective  in treating ischemic stroke. Improved patient outcomes with the use of thrombolytic therapy could generate optimal patient outcomes in Africa , as lack of thrombolysis program was said to add to the existing shortage of resources . Thrombolysis could be safely administered up to 6 hours after witnessed stroke onset . However, delayed presentation to the hospital was the main barrier to rt-PA administration in Lebanon .
Rehabilitation services for patients with stroke was highlighted in seven articles. Of importance was the common finding that rehabilitation represented a key part of stroke care for the majority of patients. However, despite much research revealing the necessity of rehabilitation, the intervention remained limited in most LMICs. Recommendations were for rehabilitation to commence as early as possible after a witnessed stroke. SU team or just stroke team (in absence of SU) included physiotherapists, occupational therapists, speech and language therapists, stroke physicians, nurses and healthcare assistants . Referral to in-patient rehabilitation varied depending on the approaches to stroke care, as introduction of SUs and multidisciplinary team in some LMICs was associated with a huge increase in referrals. The mean time from admission to referral for physiotherapy was 3 days . The majority of patients referred utilized physiotherapy and the mean number of physiotherapy sessions received during in-patient care in the sampled urban hospitals varied. For example, physiotherapy was utilized 2 sessions per week in Nigeria , 2 sessions per week in Rwanda and Tanzania respectively, and 3 in South Africa .
Two reports highlighted stroke prevention strategies, with approaches including blood pressure control, promotion and maintenance of healthy lifestyles (i.e., not smoking or smoking cessation for smokers, no binge drinking, being physically active, and a healthy diet with adequate fruit and vegetable intake, reduced dietary trans-fats, and reduced sodium . Secondary prevention of stroke, on the other hand, included blood pressure control, antiplatelet and lipid-lowering therapy, homocysteine-lowering therapy, and self-management and family support .
Stroke care outcomes
Regarding stroke care outcomes, 7 studies (34, 35, 39, 41, 47, 49) reported a total of six dimension of stroke-care outcomes, illustrated on the right side of Fig. 1. They were quality of stroke care practice, functional independence, length of hospital stay (LOS), mortality, living at home, and institutionalization. Of note, was LMICs with better structure and processes of care such as availability of SU, patients were more likely to be alive, independent, and living at home 1 year after stroke . On the other end, LMICs with no requisites had unsatisfactory or poor stroke service delivery  and poor stroke care practice . Thrombolysis , mechanical thrombectomy in combination with pharmacological thrombolysis when indicated improved functional outcomes . Utilization of in-patient physiotherapy (PT) was significantly associated with reduced LOS , and reduced mortality . Absence of rehabilitation on the other hand was associated with reduced level of function, evidenced by increased modified Rankin scale (mRs) score . Studies had further shown that a structural dimension such as multidisciplinary stroke care teams resulted in long-term reductions in death, dependency and the need for institutional care, facilitated earlier discharge to the home, increased the likelihood that patients would regain independence in activities that support daily living, and resulted in fewer patients requiring long-term institutional care in some settings within LMIC .
In this paper, we extracted data from twenty articles that highlighted stroke care in LMICs with the guide of the DM on quality of care as a conceptual framework. Nineteen dimensions of stroke care emerged, covering stroke-care SPO. Seven of the 19 dimensions that emerged were structural. They included a SU, accident and emergency department, multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies [33, 34, 38, 40, 41, 42, 45, 46, 47, 48, 50]. Structurally, this review showed that there were few or no SUs in various settings within LMICs. As a result, stroke service delivery in those areas was unsatisfactory or poor . The development and running of SUs was a key recommendation in most countries including the developing ones . In LMICs, fast-tracking was needed for the establishment of SUs to revolutionize stroke care provision, with the great possibility of improving stroke outcomes . Availability of designated accident and emergency departments with specific stroke clinical guidelines and functional and standardized multidisciplinary teams for acute stroke care were associated with good stroke care practice . But the LMICs are grappling with the number and variety of stroke specialists, for example, very few neurologists and almost no speech therapists to form and run efficient teams . There is a need for those countries to develop a competitive edge through provision of equal opportunities for career advancement, lifelong learning, and to develop policies that promote loyalty and retention . Further on, this study highlighted that most LMICs countries, had inadequate facilities for neuroimaging and thrombolysis, inadequate ambulance services especially in rural areas, limited education efforts and awareness about stroke, inadequate training of emergency physicians , and inadequate public insurance or financial support for rehabilitation care . There is a pressing need for health care providers to lobby and secure direct health policy support from the state or national level for stroke care  to minimize these challenges.
Six dimensions of stroke care processes that emerged in this review were assessment and diagnosis, referral, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies [33, 34, 35, 41, 42, 46, 47, 48, 49, 50, 51, 52]. Undoubtedly, the structural limitations in LMICs has a bearing on stroke care stroke processes. This review showed that stroke assessment and diagnosis is challenged by inadequate availability of neuroimaging [40, 41]. The role for intravenous thrombolysis as evidence-based treatment for acute ischemic stroke is known . It is cost-effectiveness even in LMICs  via its generation of optimal patient outcomes in Africa , and that, lack of the same adds to the existing shortage of resources . We, therefore, share the observation that there is a great need for ministries of health and governments to embrace “the trends”, strengthen radiology departments and adopt thrombolysis therapy in stroke care protocols. What was also agreeable in this review was the common finding that rehabilitation represents a key part of stroke care, although, clearly, the interventions remain extremely limited in most LMICs. Research recommends that rehabilitation should commence as early as possible after stroke, within 24 to 48 h . However, access to rehabilitation services remains low in LMICs, due, mostly to structural roadblocks such as limitation in number and variety of rehabilitation professionals [40, 41]. This review highlighted the need for a two-tier stroke-prevention strategy: primary preventive approaches for stroke, which included blood pressure control and promotion and maintenance of healthy lifestyle , and secondary prevention strategies such as blood pressure control, antiplatelet and lipid-lowering therapy, homocysteine-lowering therapy, self-management, and family support . Primary preventive strategies remained key to the prevention of stroke and must be embraced in all efforts aimed at improving stroke care.
The last six dimensions that emerged were stroke care outcomes that included quality of stroke care practice, functional independence, LOS, mortality, living at home, and institutionalization. Of note was that the LMICs with better structure and processes of care such as the availability of a SU, patients were more likely to be alive, independent, and living at home 1 year after stroke . Comparatively, countries with no requisites had consequent poor stroke service delivery . In the LMICs where thrombolysis was administered in combination with mechanical thrombectomy there was significant improvement in functional outcome [34, 45]. Further, rehabilitative therapy was associated with reduced LOS , and reduced mortality . On the other hand, reduced level of function was reported in the situations of absent rehabilitative treatment . Additionally, where multidisciplinary teams were implemented, long-term reductions in death, dependency, and early-discharge was reported . There is, therefore, a compelling need for improved structure: allocation of resources, appropriately trained personnel, and recognition of the importance of an integrated team approach to the delivery of stroke care in LMICs. This will ultimately lead to the improved delivery of stroke care . and significantly improved outcomes. Many lives could be saved and the quality of life improved for the current and future generations.
This scoping review focused on a broad research field of stroke care. And 2010 to 2017 is reasonably a wide range of publication year, having only 20 articles as meeting inclusion criteria sounds spurious. However, the included articles were very specific to the study question and so could be reflective of stroke care in LMICs. Lack of strict adherence to methodological quality that goes with scoping review might affect the quality of this review. Constant checks with research team members added rigor to the study process. Additionally, the study precluded addressing issues related to personnel availability, program funding, and training institutions across the LMICs to train stroke care specialists.
Inconsistencies exist in the way stroke care is advanced in LMICs. This is reflected in unsatisfactory stroke care structure, processes and outcomes in some settings of study area. There is a need for stroke care settings to adopt stroke care quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke . SUs and rtPA administration could be considered as both a structural and process necessity. It is clearly an imperative in LMICs such as Malawi for the care of patients with acute stroke, whose numbers are increasing exponentially.
This research was part of the major PHD project at the University of the Western cape where project approval was granted. We thank our colleagues from the Medical Rehabilitation college who provided insight and expertise that greatly assisted the research through providing technical assistance during data searching and ICT service.
We thank Leslie Glickman, PHD for her great comments, insights in some areas of the study, and language editing that greatly improved quality of the manuscript. Stella Mpezeni, PT; Haules Zaniku, PT, Justice Amadi, PT and Eunice Muvindi, OT and Fungai Makotore, OT for peer support during literature search, data extraction and write-up.
We would like show our gratitude to Cedric Pahuwa, MPH, principal Medical Rehabilitation College for the material and time support to see this project to the end.
GC: Primary author, conceived of the study, literature review, write up. AR: primary supervisor, expertise regarding the course of the study. The authors contributed to refinement of the study protocol and approved the final manuscript.
This work relied on the author’s saving and had no formal funding.
Ethics approval and consent to participate
Ethics approval was received from the University of the Western Cape: registration number 15/6/31; College of Medicine Research and Ethics Committee (COMREC) of the University of Malawi: approval number P.10/15/1819. As this is a scoping review there was no need to seek approval for participation.
Consent for publication
The authors declare that they have no competing interests.
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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.


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Believe it or not, die-cutting, or the act of cutting out shapes using dies, has a long history that dates back to the mid-1800s. According to Colvin Friedman, die cutting started as a way “to cut leather for the shoe industry more efficiently.” Back then, making shoes was very labor-intensive and time-consuming since the holes in the leather were individually punched by hand. The manual process yielded many inconsistencies between the shoes, hence the introduction of die cutting. Since then, cobblers were able to “create sole patterns that could be reliably replicated through the die cutting process.” With the advent of the mallet handle die cutting machine came the mass production of soles and standardized sizes for the masses.
It wasn’t until the early 1900s when further innovations in dies and die cutting machines were invented. The creation of the swing-arm clicker press helped the shoemaking industry and other industries to die cut different shapes and sizes with various sized and shaped dies. This then started the mass production of products like plastic, metal, tubing, and food items.
The 1950s saw the invention of hand-held die cutting tools and small table machines, which were mostly used for homes and schools. What started as a simple and convenient way to help cobblers speed up the shoemaking process has turned into a staple tool in every crafter’s home.
Welcome visit our official website ：http://jigscut.com

domain: history


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Google Lens gets offline translate capabilities on Android
This feature is being rolled out as a server-side update.
Google, since last year, has been working on adding offline translation capabilities to Google Lens. Now, the company has taken one major step in the direction by bringing offline translation capabilities to Google Lens on Android.
As per a report by 9To5 Google, to use this feature, users will have to download the latest version of Google Lens on their Android smartphones. The good news is that Google is rolling out this feature as a part of the server-side update so you don't have to update the app manually to get this feature.
As far as the usage is concerned, once the app has been updated the first time users open the app there will be some adjustments to make. The report notes that when users open the app (after updating) they will have to open the Translate filter and click on the ‘Pairing' pill under Google Lens to open the ‘Select Language' screen. Here, they will see a ‘Tap to download' prompt that will highlight a new button to various languages. This new button will enable users to download the specific language and on downloading it will be an indicator of the languages that the app will support in the offline translation mode.
Now, before the downloading begins, Google will show users how the offline language pack is and how much storage space is available on their smartphones. Once everything is okayed and downloading is complete, Google will show a checkmark on the downloaded languages.
The report also notes that Google Lens' offline translate feature will start translating the text even before users have clicked the shutter button. The results will be overlaid on the live preview and there will be a bottom sheet that will show the translation occurred along with giving users the option to copy all of the translated text.
Follow HT Tech for the latest tech news and reviews , also keep up with us on Twitter, Facebook, Google News, and Instagram. For our latest videos, subscribe to our YouTube channel.

domain: news


Now you can join the auction of residential flats although sitting in the relief of your home or office...
CHB To Launch New Flats Scheme In Sector 53 Quicklyadmin, , General, News & Media, Chandigarh Housing Board, New Flats Scheme, Sector 53, 0
The Chandigarh Housing Board is planning to introduce another housing strategy for residents.The strategy will be launched in Sector...
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That moment when you just want the earth to open up and swallow you: I’m lucky not to have had too many of those in my life so far (is that a good thing or not?), but one small example springs to mind.
I was working as a camera trainee on a TV drama series in the late ’90s. One of my regular responsibilities was the clapperboard: holding it in front of the lens, saying something like “137, take 1”, clapping it, and then ducking out of the way so as to be out of shot.
The scene in question involved looking over a character’s shoulder as they watched TV, with the rest of the room visible in the background. The camera crew were huddled in the corner behind the actress, so there was nowhere else for me to stand, so once I’d clapped I had to run out of the room completely in order to be out of shot once the action started. The moment arrived and I got into position. All was silent. The camera started rolling. I called the shot number and clapped the board. I turned and started to sprint toward the door. I felt a cable tug at my ankle. I heard a crash. I turned round to see everyone looking at the floor, where the television was laying, face down, screen smashed. Then everyone looked up at me.
Fortunately the calmly professional propmaster had a spare TV ready to go, and the scene was completed with only a few minutes’ delay. But my colleagues never let me forget it…

domain: artistic


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Council: Intersection project to begin April 25
Barnesville Village Council met March 29 and discussed the intersection widening project.
The widening project is at the intersection of State Routes 800 and 147, also known as S. Chestnut Street and Leatherwood Road. Village Administrator Roger Deal said the intersection is being widened to allow easier turning radius for semi-trucks and over-size loads.
The project will begin April 25 and have a completion date of July 31, 2021.
Meanwhile, Deal said the village received a second grant for $250,000 from Appalachian Regional Commission in regard to the Slope Creek waterline. He said they have secured two grants now and a zero percent interest loan from the EPA, and still waiting on one grant source.
Deal said with the American Rescue Plan Funding, he would like council to consider the Westview Drive Lift Station as the top priority for the funds. Council agreed and an engineering firm will be contacted.
Meanwhile, Deal presented council with a quote and literature from Bain Enterprises on a valve exercise machine. The village is required by the EPA to have a valve exercise program. The village has $40,000 budgeted with hopes of the additional $40,000 from a BWC Grant, however, this grant has been discontinued. Deal asked council to consider this purchase. After discussion, Deal is to contact the company and have the machine brought down for a presentation to council.
In other business, Fire Chief Tim Hall asked for council’s permission to apply for the JB Green Team Grant totaling $5,300 with the village’s share of $1,300. Council agreed.
Councilman Jamie Betts asked Hall how many paramedics are in the department. Hall said they have two paramedics, four intermediates and the remaining are Basic. Betts said he would like to look into options to fix that. Hall said they are getting by, however, they are looking into different plans for the future.
In other business, councilman Terry McCort expressed his appreciation to Barnesville Hospital and Barnesville EMS for their speedy service.


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- Technical: 2.5,
short rock band 3, (alpine 3.0)
two attempts I finally climbed this little peak. It is only a hike but approaches
an easy scramble near the summit and on a couple sections when gaining the ridge. In
winter it becomes a slightly more serious endeavour. In stead of my regular prattle
I’d like to take this opportunity for a little sermon (yes, some may be rolling their eyes).
In a notch on
the ridge that I entered to avoid loose wet snow, which is completely avoidable in the dry, and which rates as moderate scrambling,
I had a foot hold pull out. Nothing untoward happened as I had 3 other points
of contact and I would not have even thought twice about it until I later learned that a fellow climber on the RMB forum had
encountered loose terrain on the same weekend and was fairly significantly hurt. Getting
on my little soapbox for a moment I cannot stress enough that even easy hikes can become terribly costly. A simple miscalculation,
or bad luck, is sufficient to turn a wonderful day in the outdoors into a nightmare from hell.
On easier terrain, such an error will usually result in an injury that one can often times walk (err hobble) away from. On difficult terrain such an error can likely mean death or horrific injury. It is a fact that one is gambling with ones life, and the lives of their partners
who will often risk themselves to help an injured partner, when they engage in these activities. Mountaineering principles have been established that aim to minimize such risk. Gear like ice axes, crampons, helmets, rope and ice/rock protection all reduce the potential for injury,
if used properly (although they are absolutely not fool proof). I stress that
anyone journeying into the outdoors must do so with solid preparation and with the gear and knowledge to minimize risks.

domain: hobby


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Greene Co. Library to celebrate dedication of newly-renovated building
SNOW HILL — It has been a long wait for Greene County folks to get updates to the most-used service in the county.
Extensive community efforts, construction and a variety of funding sources will culminate in the Greene County Library’s Dedication Ceremony at 3 p.m. Sunday.
“I tell you, we’re very, very excited,” Agnes Ho, Neuse Regional Library director, said. “Finally, the day is here … so we can dedicate such a nice Greene County Library for the community.”
The afternoon’s events will include entertainment by the Greene Central High School Marching Band and Ramblers, Greene County Middle School Chorus, Greene County Suzuki students and Snow Hill singer, Jamison DeLallo.
Greene County Schools Superintendent Patrick Miller, his wife Rebecca — Greene Intermediate School music teacher — and their two sons; along with Angela Tyer, Greene Middle School chorus teacher; and Luke Hancock, Greene Central High School chorus teacher, will sing the national anthem.
Ronald McDonald will be available to entertain the children.
A highlight of the program will be an appearance of the Wells Fargo stagecoach. The public is encouraged to come early to view the famous stagecoach and have their pictures taken with it.
Head Librarian Laquita Davis said the long-awaited dedication ceremony is exciting.
“I’m expecting a very large crowd to come and enjoy the stagecoach, Ronald McDonald and the local officials,” she said.
Peggy Greene, Greene Library Board chairwoman, was instrumental in pulling together much of the funding to make the project happen.
“It was our dream to build a new library,” she said, “but our small county could not afford to do this. So the next best thing was to renovate our present site. This spacious library will serve our residents for years to come.”
The project began in the minds of library personnel and volunteers a number of years ago. In November 2010, the Golden LEAF Foundation awarded $190,545 to expand the library.
Fundraising efforts and donations generated about $171,000. The Neuse Regional Library Board donated $100,000 and Greene County commissioners donated $50,000 and their large meeting room at the County Complex.
“That’s why I think this is truly a Greene County community project,” Ho said about the donation efforts that totaled $1.35 million.
Construction began in September 2011.
The funding paid for a new glass front entranceway, expansion inside the complex, large information desk, a young adult area and more computers.
The new addition houses children’s, small business reading and program areas.
There is also a kitchen, handicap-accessible restrooms and plenty of natural lighting.
Ho said the Cooperative Extension Service performed a community survey ranking the most-used services in the county. The library ranked No. 1, she said.
“I really think the library plays an important role in the community,” she said. “… I would tell the students, ‘The library card is the key to success.’ ’’
The Greene County Library was founded in 1934 by the Mother’s Club in the American Legion building, Justin Stout, regional special projects manager, said. After the Neuse Regional Library took it over in 1962, it was moved to its present location.
The new expansion and renovation was finished in June. Davis said the library has been busy with patrons since the work was completed.
Greene said people considering a move to a new location often ask about the schools and the library.
“I am now so proud to say that, along with the best school system, we also have a great library,” Greene said. “This was truly a team effort, and we are so proud of this facility.”
For information about the library or dedication ceremony, call the Greene County Library at 252-747-3437.
Margaret Fisher can be reached at 252-559-1082 or firstname.lastname@example.org.
What’s happening: Greene County Library Dedication Ceremony
When: 3 p.m. Sunday, Sept. 16
Where: Greene County Office Complex, Martin Luther King Jr. Boulevard near Kingold Boulevard, Snow Hill

domain: library


text:
Bathroom furniture, Square Small Rectangular Bathroom Sinks Undermount: Modern Rectangular Bathroom Sinks Ideas
Published at January 03rd, 2018 05:48:16 AM by didin
Tabbed as rectangular bathroom sinks with two faucets area of interest as well as kohler rectangular vessel sink topic with small rectangular bathroom sinks area of interest also rectangular top mount bathroom sink subject, kohler rectangular bathroom sinks discussion plus kohler square sink undermount object, Bathroom furniture, So don't forget to check out the main article in Modern Rectangular Bathroom Sinks Ideas
© 2018 Bathroom design. Reproduction without explicit permission is prohibited. All Rights Reserved.

domain: design


The COVID-19 pandemic brought air quality to the forefront of the transit industry. In the summer of 2022, due to the immediate need to understand the issue, the Transit Cooperative Research Program (TCRP) conducted its first Insight Event. TCRP Insight Event--Air Quality in Transit Buses explored how air quality inside transit vehicles, especially buses, may contribute to the spread of infections. During that event, presentations and conversations about dispersion, ventilation, circulation, and filtration issues were held. Presentations from the event and the literature search results are available on the TCRP Insight Event web page at https://www.nationalacademies.org/event/06-21-2022/trb-tcrp-insight-event-air-quality-in-transit-buses.
Since that event and the end of the pandemic’s restrictions, the public transit industry has learned that air quality inside transit buses matters to bus operators and passengers. There is an increased focus on reducing the concentration of pathogens containing respiratory aerosols and other harmful pollutants in the air inside a bus cabin. Transit agencies are working to increase operators and passenger confidence in air quality. With increased confidence, riders will return, and it will be easier to hire bus operators.
Transit systems are analyzing the current air quality inside their buses to better understand current airflows and possible risks. Measuring and controlling air quality inside the bus cabin has proven difficult. Buses idle, constantly open their doors to embark or disembark passengers, and are exposed to traffic-related air pollutants, such as exhaust.
This reality has not hampered the desire to improve air quality inside cabins. Transit agencies are employing the following solutions to mitigate poor air quality: dilution, which consists of bringing more fresh air inside the bus while sending indoor air out; filtration with the use of better-quality filters; and cleaning, including the use of ultraviolet light and photocatalytic oxidation.
Research is needed to find clear solutions to improve air quality on buses for operators and passengers. Transit systems are doing the best that they can to protect their employees and passengers. However, research can provide information to improve air quality and standardization of practice.
The objective of this research is to create a research document that helps transit agencies understand air circulation inside a typical 40-foot heavy-duty transit bus and finds solutions to protect employees and passengers without decreasing passenger comfort, safety, and reliability of the system. The research should help guide the development of future design and performance criteria to support better transit rolling stock procurement and heating, ventilation, and air conditioning (HVAC) operations in emergency conditions (e.g., airborne diseases and wildfires).
The research deliverable should include the following:
- A comprehensive review of existing studies about air circulation inside buses and other relevant passenger vehicles that summarizes:
- Challenges and concerns, and
- Methods for improving air quality inside buses, such as outdoor ventilation, HVAC filters, and other technologies that manage indoor air pollutants.
- Report on the existing air management systems installed or retrofitted by transportation agencies during the COVID-19 pandemic, their benefits, and how those benefits were validated.
- Summary on the constraints and considerations for potential retrofitting of bus air management systems, considering the interior and external envelope of the bus.
- Recommendations for the design criteria of the optimal air management system for a bus vehicle in revenue service, such as outside air exchange rate, recirculated air, airflow patterns, and filtration efficiency.
- Recommendations to move research forward and for future standardization, including recommendations for different bus typologies (cutaways, articulated, etc.).
The research plan shall be divided into tasks that present, in detail, the work proposed in each task. The research plan shall describe appropriate deliverables that include the following (which also represent key project milestones):
- An Amplified Research Plan that responds to comments provided by the project panel at the contractor selection meeting;
- An interim report and virtual meeting that occurs after the expenditure of no more than 40 percent of the project budget;
- A draft final report;
- A final report; and
- A technical memorandum, titled “Implementation of Research Findings and Products” (see Special Note K).
STATUS: Proposals have been received in response to the RFP. The project panel will meet to select a contractor to perform the work.


text:
Advanced Materials Interfaces have published an article by Qi et Al, which investigates opportunities for the ‘use of membranes for extracting, reclaiming, and purifying alkali metals from aqueous feedstocks’. Their findings suggest ‘interesting implications for ion batteries and other energy conversion systems’.
For the experimental section, Silson’s Si3N4/Si chips with 5 µm-sized holes were used to prepare free-standing CNMs (carbon nanomembranes) for mass loss and ion transport measurements.
The conclusion finishes: “In this respect, the mechanical strength and the high water permeance of pyrene-derived CNMs promise advances in their scalability and can potentially be beneficial for use in such settings as ion-exchange, electrodialysis, and energy harvesting membranes” – follow this link to read more!
MDPI have published an article by Beaudier et Al which explains their investigation of "the effects of targeted irra...


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MPD: One-third of Madison’s currently stolen vehicles from west side
MADISON, Wis. (WMTV) - The west side of Madison accounts for over a third of the currently reported stolen vehicles in the area, police say.
Madison Police Department’s Criminal Intelligence Section released the total reported stolen vehicles in Madison and Dane County, which shows 30 cars are listed as stolen. Of those 30, 11 were stolen from the West District.
Madison’s West District includes Elver Park, West Towne Mall and University Ridge Golf Course.
Police officers urge anyone with information on the stolen vehicles to call the department at 608-255-2345. Those who want to stay anonymous can call Madison Area Crime Stoppers at 608-266-6014, or leave a tip online.
MPD also released these tips to help avoid theft:
- Lock all car and residence doors.
- Leave exterior lights on at night or use motion detecting lights.
- Keep valuables out of sight.
- Remove valuables from your vehicle when unoccupied, including extra keys or garage door openers.
- Keep your garage doors closed and locked when not in use.
- Report all criminal and suspicious activity immediately.
Copyright 2021 WMTV. All rights reserved.

domain: law


60% Cotton 40% PolyesterMachine WashableSingle duvet cover and pillowcase set included
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Official Sunderland FC Football Strip Bedding SAFC Duvet Set HPQNONULN


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If you are looking for an alternative welcome drink that can provide energy without the side effects of coffee, are you interested in trying a cup of warm green tea?
This is not just any green tea. Introduce, Yerba Mate – a new rival of green tea in the world of health.
What is yerba mate?
If green tea trees come from the land of bamboo, China, yerba mate is an herbal drink brewed from the leaves of the mate tree (Ilex Paraguariensis). You can only find mate trees are grown in rainforests in Argentina, Chile, Peru, Brazil, Uruguay, and Paraguay – and are generally used as raw material for medicines.
In the world of alternative health, the leaves of mate trees are used as stimulants to relieve physical and mental fatigue, as well as chronic fatigue syndrome.
This plant is also used to deal with complaints about heart problems, including heart failure, irregular heartbeat (arrhythmia), and low blood pressure. Some people use leaf mate to improve mood and manage depression; to relieve rheumatic headaches and aches; cure bladder tract infections and kidney stones, and as a laxative.
Similar to green tea, the leaves of the mate tree contain antioxidant mateine which is linked to a myriad of health benefits such as weight loss and prevention of heart disease.
Leaves from the mate tree contain 15 amino acids, 24 minerals, also a series of important vitamins. In addition, this herbal tea also contains caffeine, quercetin, theobromine and theophylline, saponins, and chlorogenic acid which are commonly found in coffee, chocolate, and regular tea. These active ingredients work to stimulate the central nervous system, reduce appetite, increase muscle relaxation and function as a diuretic.
Nicknamed as having the power of coffee, the health benefits of tea, and the euphoria of chocolate, it’s no wonder the yerba mate is a national drink from the six countries above. For centuries, a number of tribes in South America have been consuming yerba mate to achieve rejuvenating effects, such as clear skin and vitality.
How yerba mate can help slimming down
The content of the mateine compound in yerba mate is reported to help improve the body’s metabolic performance and increase your energy, which helps burn fat in the process.
Yerba mate is also known to have a relaxing effect that can calm your emotions and make you more immune to the habit of emotional eating when stressed. The effects of this herbal tea have also been known to stop cravings from unhealthy foods. In addition, yerba mate has been found to slow the rate of gastric emptying. This causes people who consume it tend to feel full longer and reduce the portion of overeating.
Reporting from Fox News, a small South Korean study that examined the effectiveness of yerba mate extract helped promote the fat reduction in 30 study participants who had a body mass index (BMI) of more than 35. Nominal BMIs reaching 30 or more were considered obese.
The researcher gave participants a yerba mate extract capsule which was concentrated three times a day, equivalent to one gram of extract every day. A placebo group was asked to consume empty capsules (without prior notification). For 12 weeks, those who consumed yerba extract saw their BMI fall to an average of 30. Participants did not modify their diet or lifestyle throughout the experiment.
Which is more effective for burning fat between green tea and yerba mate
The popularity of the yerba mate has lifted thanks to its alleged ability to suppress appetite and burn fat. However, evidence shows that this effect can only be achieved through high doses if there is any effect at all.
The yerba mate fat burning effect is associated with caffeine content containing around 0.56 percent caffeine, which promotes thermogenesis, a process that speeds up calorie burning. This factor has not been proven to be a more effective fat burner than catechins in green tea, although it can help reverse some of the effects of health risks associated with obesity.
The thermogenesis process of green tea and yerba mate is proven to increase daily calorie burning up to 80-100 kcal per day. But, to eliminate 500 grams of body fat, you will be required to consume 3,500 fewer calories than the amount burned. The best way to achieve your ideal body weight is to consume 500 fewer calories per day.
Each product has unique benefits in terms of weight loss. Besides thermogenesis, perhaps more important is theobromine content in yerba mate. Like caffeine, theobromine is a central nervous system alkaloid stimulant, but slightly weaker than caffeine. Theobromine is a diuretic, and also may be at least more responsible for the appetite suppressant effects of these herbs while helping to reduce water retention. Green tea has also been shown to increase fat oxidation.
If you want to try a cup of warm yerba tea, enjoy it naturally. As always, always check with your doctor before you try herbal products. Yerba mate may not pose a risk for healthy adults who drink it once or twice. However, several studies have shown that large doses of yerba mate over a prolonged period show an association with an increased risk of several types of cancer, such as cancers of the mouth, esophagus, and lungs. Consumption of yerba tea combined with smoking habits also seems to greatly increase the risk of cancer.
In conclusion, yerba mate is a healthy tea, but it is not necessarily more healthy than other vegetable drinks, such as coffee. however, however, this herbal tea has a unique nutritional composition.

domain: food


text:
2013 Performance Showcase
June 14, 8:00pm, Cossitt Hall, Colorado College Campus
For one night only, join us for an intimate evening of dance to include original works by Ayo Jackson and Rosalynde LeBlanc Loo, former members of the Bill T. Jones/Arnie Zane Dance Company, Colorado College Artist in Residence Patrizia Herminjard, alumna Casey Avaunt, collaborative works with the Summer Music Festival and spoken word poetry by members of the Cross Genre Writing Workshop class taught by Idris Goodwin and Steven Hayward.
Tickets available for purchase starting June 3 at the Colorado College Worner Center, 902 N. Cascade
$15 general admission/$10 student with ID/$15 with CC ID
Seating is limited and advanced ticket purchase is encouraged
Performance Showcase Friday, June 14 at 8 p.m., Cossitt Hall, 906 N. Cascade Ave.
Call 719-963-1893 or e-mail firstname.lastname@example.org for more information


text:
This chapter distinguishes body from flesh and shows the latter to be, first, haptic, which is to say constituted and maintained as flesh by touch in its many varieties; second, self-contiguous and bounded, separated in fact and experience from other bodies of flesh, while also located in time and space; third, a gift received from the caresses of others, without which flesh can neither come to be as such, nor continue in being; and fourth, fragile and mortal, located in a world in which fleshly pain is a constant threat and a frequent companion, and in which death, the end of flesh, is always close at hand.
This chapter shows what human flesh would be like were it not damaged, and does so from a Christian point of view, by describing the flesh of Jesus Christ during the period from his conception to his death on the cross (natal flesh), from his resurrection to his ascension (resurrected flesh), and from his ascension onwards (ascended flesh). As natal flesh, the book argues, his flesh was exempt from the ordinary damage of pain and mortality except as these served particular purposes. The chapter shows, in its analysis of this and its engagement with counterviews, that human flesh's ordinary subjection to these things isn't essential to it, and begins to sketch what flesh would be like were it not so subject.
This chapter shows what it means for human flesh to cleave to—to be made intimate with, incorporated into—the flesh of Christ through baptism. Baptism is depicted as a matter of the flesh and as an act that newly relates the flesh of the baptized to Christ's flesh. Paul's discussion of these matters in the Corinthian correspondence is interpreted, with special attention to what it means to say that the Christian's bodily members are, analogically and participatorily, Christ's. Being intimate with one kind of flesh—namely Christ's—means that some other kinds of fleshly intimacy are ruled inappropriate; the scriptural language of fornication and idolatry is presented and discussed as a way of clarifying this, and the chapter argues that appropriate Christian fleshly conduct is better presented by way of hagiography—writing the lives of those who exhibit it—than by way of argument or codification.
This chapter shows what it is to be clothed, and what functions the wearing of clothes serve in human life. It shows the importance of nakedness in baptism and argues that there is no distinctively or properly Christian clothing: no clothes intrinsically proper to, or improper for, Christian flesh. Local sartorial conventions, however, may be observed by Christians, and should be unless they carry with them a signal that they are more than conventional by being rooted in the order of being. If they carry that signal—as locally gender-specific modes of dress, for example, often do—then they can become both fornicatory and idolatrous. The chapter argues that Christians have a radical freedom with respect to dress because of their cleaving to the flesh of Christ.
This chapter shows what it is to eat and drink and asks what is appropriate in that sphere for Christian flesh. There are, for Christians, no forbidden foods, and none required. All are on a par at least in that all eating is intimate with slaughter (whether of plants or animals). The sole exception is eucharistic eating, and this shows that all non-eucharistic eating ought to be accompanied by lament as well as by delight. Fasting is analyzed, depicted as a proper Christian response to this situation, and articulated with both eschatology and eucharistic theology. Gluttony and other forms of scandalous eating are treated, and the mistakes evident in them shown.
This chapter analyzes the varieties of human fleshly exchange as these appear to Christians. Fleshly contacts fall on a spectrum from the life-giving caress to the life-taking wound. Fleshly wounding is concupiscent: it seeks domination and control, and caresses of this kind are inappropriate, it is argued, for Christian flesh, while celibacy and virginity are depicted as characteristically Christian modes of responding to the connection between copulation and death. But there are no caresses whose form specifically forbids them to Christians, and this is argued with respect to three examples: masturbation, cunnilingus, and sodomy. The topics treated in this chapter are framed by and aimed at a depiction of caressing the flesh of Jesus, with which the chapter concludes.

domain: literature


EV may well be the buzzword of our instances, but battery is not the only selection when it comes to long term fuelling. From Porsche to BAC, our traditional vehicle storage staff considers some of the organizations pushing substitute fuels from drawing board in direction of actuality
The situation for an EV substitute
The automotive business has taken BEV (battery electrical cars) to heart with a stream of new designs launched onto the open market place. Proper now, with the great climate, EV owners are enjoying elevated assortment but claims on social media of ‘charger rage’ suggest the positives of longer street journeys are outweighed by the probability of an argument at the providers.
What is charger rage, you inquire? Apparently it comes about when a big variety of autos are queuing to charge, and drivers get annoyed or when tempers flare due to a driver trying to leap the queue. Thankfully, these circumstances are unusual, and we cannot disregard the sheer selection and diversity of electrical cars now supplied: from supercars to sports activities autos and vans to family members autos there has never ever been so a lot option.
But is there yet another way? We currently know the carbon expense of producing an EV requires longer to ‘pay back’ than the equivalent petrol vehicle, in accordance to a really sincere report by electrical automobile producer Polestar. Include that to charger concerns, reduced assortment in winter and a substantial buy value when new, 1 hopes a ideal substitute will be located. And that is prior to we contemplate the misplaced components an enthusiast would miss, namely engine noise, guide gearboxes and all round mechanical soul and character.
British supercar brand BAC, makers of the street-legal Mono single seater, not too long ago announced a Hydrogen fuel cell research e-Mono which will lap Silverstone more quickly than the petrol-powered Mono-R even though offering a true-planet assortment of 166 miles.
One particular of the primary problems of converting a 555kg Mono supercar to zero-emissions is how to retain its ultra-light bodyweight, specially as converting to battery-electrical would make the vehicle 50% heavier. In addition, even though BEV autos can go just as quickly as a petrol-engined substitute, the joy of a track-centered supercar is its agility and responsiveness via corners.
It was accepted that the blend of a fuel cell, a hydrogen storage tank and a battery pack would be heavier than a petrol engine, but if stored to a manageable bodyweight, it would not compromise the Mono’s legendary agility. The consequence is a battery pack which generates 265 bhp, with a fuel cell making 107 bhp, and 3kg motors on the front wheels which supplies an further fifty five bhp per motor and all-wheel drive.
The layout was place via a series of simulation exams, in which the e-Mono shaved two seconds off the Mono R Silverstone lap time (two.04.three vs two.06.three). The blend of fuel cell and battery resulted in the capability to run ten quickly laps of Silverstone among refuelling. On-street assortment is calculated at 166 miles on the official WLTP cycle, roughly 140 miles in reasonable use. Enhancements in fuel cell efficiency will allow an boost in assortment of a additional 50% by 2024, with no any boost in powertrain dimension or bodyweight.
Meanwhile, Porsche has commenced trials of its very own synthetic fuel which will be compatible with unmodified combustion engines. The organization has announced an ambition of developing a plant for industrial manufacturing of synthetic fuels on an industrial scale, making fifty five million litres by 2024, and approximately 10 instances that volume by 2026.
Porsche CEO Oliver Blume outlined the motive for the task: “Their benefits lie in their ease of application: e-fuels can be utilised in combustion engines and plug-in hybrids and can make use of the current network of filling stations. The basic thought behind these synthetic fuels is that there is no modify to the engine required, not like what we have observed with E10 and E20, so genuinely, everyone can use it, and we are testing with the typical specs of pump fuel.”
So, even though electrical cars are the present darlings of the automotive planet, our zero-emissions long term could supply a assortment of propulsion possibilities. It is not past the realms of probability to picture a fuel station providing synthetic fuels, hydrogen, and electrical charging beneath 1 roof enabling owners to make a option. There is no doubt that enabling ICE autos to reside on by way of e-fuel is hugely beneficial, and it looks the automotive long term could be brighter than numerous of us had dared to hope.
Pick Windrush for EV storage and past
At Windrush, we’re proud to be open-minded, prepared to embrace traditions even though moving with the instances and adapting our luxury vehicle storage remedy to what ever lies ahead. Considering that our formation, we’ve welcomed every single stripe of ICE vehicle to our services in central London and the Cotswolds, adapting our prestige vehicle storage remedy to the specifics of every single personal model. Meanwhile, in present day instances, we’ve evolved to turn into professionals in EV storage – and rest assured that we’ll proceed to supply the greatest lengthy phrase vehicle storage remedy, what ever the long term of fuelling.
Flip to Windrush for the highest specifications in prestige vehicle storage. We’re waiting to hear from you on [email protected] kingdom


text:
ALBUQUERQUE, NM—Despite being overcome by a profound realization just minutes earlier that challenged his long-held beliefs and promised to forever alter his daily existence, sources confirmed that 42-year-old Thomas Wilson’s epiphany had fully worn off during his drive home Wednesday. The deeply affecting and eye-opening revelation, which in an instant had caused him to completely reassess his priorities, was reportedly pushed to the back of Wilson’s mind as he stopped to fill up his car with gas, fading to just a fraction of its initial impact moments later as he began listening to a podcast on his vehicle’s stereo system. According to reports, as Wilson shifted his focus to navigating road construction and merging onto a particularly busy stretch of highway, the last shred of his momentous eureka moment had nearly dissolved away. At press time, the life-changing insight was fully extinguished as Wilson walked in through his front door and discovered the latest Hammacher Schlemmer catalogue waiting in his mail.
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text:
This service is not available, please contact for more information.
Union Triathlon 5K
- 18 US dollars$18
Once you've completed the Cycle and Strength portions of the Union Triathlon, you'll hit the road and run or walk a 5K. All levels are welcome.
651 485 7357


text:
Poas Volcano from Jaco
Walk in the misty cloud forest and be mesmerized by one of the largest craters on earth. Poas Volcano is a partially active volcano with steaming and sulfuric gas manifestations. Then you can choose between La Paz, which is an ecological attraction with waterfalls and a rescued wildlife or Doka Coffee Plantation that will teach you the entire process of coffee selection, roasting, tasting and packing.
See the specific details of this tour so you don’t miss anything
- Tour length: All day. Departs Los Sueños at 7:30am
- Includes: Transportation, bilingual guide, entrance fees, breakfast, lunch, hike.
- What to bring: Comfortable clothes, light jacket, raincoat, walking shoes, hat, camera and sun block.
- This is a private tour

domain: travel


How New York’s Lower East Side inspired new ways of seeing America
The Harlem riot of 1935 not only signaled the end of the Harlem Renaissance; it made black America's cultural capital an icon for the challenges of American modernity. Luring photographers interested in socially conscious, journalistic...
Announcing the launch of the Princeton University Press Ideas Podcast. Listen to our first episode.


text:
Introductory lecture notes on quantum information and computation
Eight introductory lectures on quantum information and computation, given at the University of Queensland Quantum Information and Computation Summer School (QICSS) in 2002.
The lectures are provided in powerpoint and pdf. Powerpoint is preferable, since that way the animations will be visible. Most files
are a few hundred kilobytes. Some small changes have been made in the pdf versions to accommodate the lack of animation, so they display better. A rough text for the lectures is also provided. I’ve been told that a good way of going through the lectures is to print out the text, and read it while paging through the powerpoint. I haven’t tried this method myself.
Reuse: Feel free to reuse the lectures in whole or part, provided it’s not for profit, and Michael A. Nielsen’s authorship is acknowledged. All lectures are copyright 2002 and 2003 by Michael A. Nielsen.
[pdf] A rough text for the lectures. (201 pages, 60000 words, 1.3 megabytes).
Page created Jan 2, 2003.
Last update April 8, 2005.


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text:
Department of Botany, Plant Cell and Stress Biology Lab, R.P.M. College, University of Calcutta, Uttarpara, Hooghly, West Bengal, India.
Background: Both lentil (Lens culinaris Medik.) and grass pea (Lathyrus sativus L.) in the family Fabaceae are two important cool-season food legumes, often experiencing water stress conditions during growth and maturity. Objective: The present study was undertaken to ascertain the response of these two crops under different water stress regimes. Materials and Methods: Different morpho-physiological and biochemical parameters were studied in a pot experiment under controlled environmental conditions. Along with control (proper irrigation, 0 stress), three sets of plants were subjected to mild (6 d), moderate (13 d) and severe (20 d) water stress by withholding irrigation at the appropriate time. Results: Compared with control, plant growth traits and seed yield components reduced significantly in both crops with increasing period of water stress, resulting in lowering of dry mass with more severe effect on lentil compared with grass pea. Foliar Relative Water Content (RWC) (%), K + /Na + ratio, chlorophyll (chl) a, chl a/b ratio, stomatal conductance and net photosynthetic rate declined considerably in both crops under water stress. Leaf-free proline level increased significantly in both crops, but it decreased markedly in nodules of lentil and remained unchanged in grass pea. Nodulation was also affected due to water stress. The impairment in growth traits and physio-biochemical parameters under water stress was manifested in reduction of drought tolerance efficiency of both crops. Conclusion: Impact of water stress was more severe on lentil compared with grass pea, and modulation of growth traits signified necessity of a detailed strategy in breeding of food legumes under water stress.
Keywords: Food legumes, growth, nodulation, water stress, yield.

domain: agronomy


Takers in Kiev! - News about real estate, Kiev, Kyiv region. Real Estate In Ukraine
Employees of the Department against organized...In Kiev region detained for bribery, another head of the village CouncilEmployees of the Department against organized crime of the Main Department in Kyiv region during receiving a bribe in the sum of 200 thousand UAH was arrested the Chairman of one of village councils Bohuslav district, Kyiv oblast (1959) reported the press Secretary of the cdoc Elena Melnik. These funds village Council Chairman (civil servant grade IV) demanded and received for the allocation of the land area of 0.75 hectares within the village Council. He was detained during receiving a bribe near the town of White Church, where he was scheduled to meet with the victims. For this fact the Prosecutor's office of Kyiv region opened a criminal case over signs of a crime h 3 in.


text:
The situation in relations between the United States and the European Union is heating up against the background of how transatlantic unity will be replaced by a transatlantic trade war.
As News Front previously reported, by the end of the year, Donald Trump has to make a decision regarding duties on European cars that are delivered to the United States, and Brussels threatened in response with retaliatory measures that affect US goods worth 35 billion euros.
In addition, according to the Politico, referring to the draft new strategy of Brussels, the EU does not intend to stop and is preparing new anti-American measures in the upcoming economic confrontation.
In particular, Ursula von der Leyen, the head of the European Commission, is proposed to consider an initiative with the creation of a new fund in the amount of about $ 100 billion, whose task will be to support European producers through the acquisition of shares, which should ensure increased competitiveness.
In addition, Brussels plans to counter the influence of the largest American corporations in Europe, namely: Google, Microsoft, Apple, Facebook and Amazon.
Earlier, Bloomberg experts called the prospect of a trade war between the EU and the US a catastrophe amid the reigning chaos in financial markets due to the US-China economic confrontation. Moreover, Brexit remains a destabilizing factor, which, based on the rhetoric of the new British Prime Minister Boris Johnson, could end in a worse outcome.EU position on Brexit remains unified

domain: finance


text:
Supported by the British Birdwatching Fair, SOPI (BirdLife in Puerto Rico) has collaborated with researchers from Mississippi State University to conduct the first ever systematic survey of Puerto Rican Nightjar’s distribution. These intensive surveys have increased the known distribution of the species, leading to its downlisting to a lower category on the IUCN Red List.
With an estimated population of 1,400–2,000 individuals, Puerto Rican Nightjar Caprimulgus noctitherus is only found on Puerto Rico. SOPI (BirdLife in Puerto Rico and Species Guardian for the nightjar) working with Mississippi State University have carried out a detailed study of the distribution of this species. They found that the species is more widely distributed than previously thought, which lead to BirdLife lowering the species’ IUCN Red List category to Endangered.
The species was recorded over a broad region of southern Puerto Rico, but several sites where it was detected have not been incorporated in any of the major conservation planning efforts on the island. Unprotected areas in Puerto Rico are experiencing increasing deforestation from residential, industrial and recreational development, causing fragmentation, loss and degradation of remaining habitat. SOPI are now supporting work with private landowners, government agencies and other NGOs to ensure the continuity and integrity of the nightjar’s habitat.
Compiled: 2013 Copyright: 2013
BirdLife International (2013) Surveys suggest that Puerto Rican Nightjar is more widely distributed than previously thought. Downloaded from http://www.birdlife.org on 31/05/2023