text:
It is often said that "Money may not buy happiness, but I'd rather cry in a Jaguar than in a bus." But why are we talking about Money suddenly? Well, small screen is something which works on 'per day', a term used for cast and crew member's daily wages. But what if these daily wages are not tendered to them on time? It is a subject to worry indeed.
Many production houses suffer these kinds of crisis and Trilogy Krikos' along with Sai Deodhar's Thought Rain Productions recently experienced these kinds of crisis which resulted in the early closure of a much awaited show Kuch Kehti Hai... Khamoshiyaan.
Now, the latest what we have heard is that Shalini Thackarey's Cinemantra Productions is in the tight spot for not giving regular payments to the employees. However, this time the issue is not with the actors, but the production house people who are baring the burnt and are striving hard to get their unpaid dues by the production house.
Sources informs, "Cinemantra currently have two shows in their kitty with lot of future projects lined up. The two ongoing shows are Color's Sanskaar and the other is Star Pravah's Ambat God. Both the shows are doing great with their TRP ratings. However, the production house is somewhere failing to keep it's behind the screen people content. There are no proper payments done for Lightmen, Cameraman, Hair dressers, Executive producers, production managers, Costume Designers, spot boys and various creative and art department persons, who have immensely contributed to the show. This all chaos has resulted in workers backing out from their work."
It is also buzzed that many production people daily visit the production house for getting their payments back but are left disappointed. We too hear that the amount of mismanagement is more seen on the sets of the Marathi show Ambat God than the one on Sanskar.
On the issue, we contacted Prashant Bhatt, fiction head of Colors but he chose not to comment on the following subject while Swapna Joshi Waghmare, Creative producer of Sanskaar states, "I am not aware of such thing happening may be it is just a rumour."

domain: economics


Brady to Cruse (letter)
December 22, 2021
Mr. Tom Cruse
2029 Ireland Grove Road
Bloomington, Illinois 61704
I have reviewed Your recent material regarding the prostatitis project and I continue to follow your efforts.
My office is in contact with the Public Health Department staff regarding their involvement with this project as well as with other medical entities, including the National Institute of Health.
I wish you success with the collaborative efforts on the part of the medical community with this important project.
Best wishes for a joyous holiday season.
William E. Brady
Back to letters page.


text:
The Dark Is Rising
Author: Susan Cooper
Series: The Dark Is Rising Sequence (Book #2)
Grade Level Equivalent:
Guided Reading Level:
Magic and Supernatural, Action and Adventure Heroes, Courage, Bravery, Heroism, Honor
On the Midwinter Day that is his eleventh birthday, Will Stanton discovers a special gift — that he is destined to seek the six magical Signs of Light. He is the last of the Old Ones, immortals dedicated to keeping the world from domination by the forces of evil, the Dark.
And for the twelve days of Christmas, while the Dark is rising, life for Will is full of wonder, terror, and delight.
Newbery Medal Winner

domain: library


text:
As one of the entrepreneurs, we cannot just sit and watch the economy falling when we know there is something that we can do to help. Our team at Stikadoo had decided to develop an online marketplace, wherein small business owners can sell their products and services online. This online marketplace is called Navalca Bay Marketplace.
As a freelancer for eCommerce and digital marketing, our business is to solve the problems of your business, and that is our way to gain. BUT in these times that we need to help each other because of the pandemic, we have decided to develop a project which is an online marketplace that could help the business owners.
As we know during the lockdown majority of small business owners are forced to close temporarily their stores. In the following months, some have decided to permanently close their business and news has said some have had already declared bankruptcy. With this kind of situation where we do not know when all these will end, should we just accept the so-called new normalcy?
Why the online marketplace? If you have heard Amazon, eBay, Etsy, and more, then you know what I mean. The chances that the merchants can get more digital foot-traffic and exposure to potential customers were very high. Since in online marketplace there will be a lot of merchants who will be selling in which this will draw more visitors to browse the website (online marketplace).
What is Navalca Bay Marketplace?
Navalca Bay Marketplace is an on the fly project, developed to contribute solutions in saving the economy and decelerate the spread of the virus by providing an online marketplace where people can still enjoy the convenience of shopping while staying at home. The marketplace focuses on the selling products and services of the local business owners of Surigao City.
Features of Navalca Bay Marketplace
Here are the features that Navalca Bay offers that all sellers can enjoy for FREE:
- Sophisticated seller’s account dashboard
- Advance management of seller’s products and services
- Real-time sales report and insights
- Customer most viewed and in-demand products
As e-commerce booms during the pandemic, some marketplaces have greatly benefited, and some have not. While Stikadoo launches the Navalca Bay Marketplace it does not stop the continuous enhancement and development to better serve the local sellers. As we know Navalca Bay is not the first online marketplace we have, but on the other side of helping the business owners during this pandemic, we are also introducing the other way of doing business in an innovative way.
“Our plans for Navalca Bay is not just for the needs of today but also for the future. So, when you sell your products with Navalca Bay Marketplace you are also preparing for your business’s future.”
As Stikadoo launches the Navalca Bay Marketplace we are also encouraging other business owners to try an innovative way of doing business not only during these times of the pandemic. If you are a seller who wants to put your products on our marketplace visit www.navalcabay.com, or if you want to start your own eCommerce website and you don't know how? We are here for you! Get in Touch with us and let’s get started.

domain: news


text:
This video shows you how to apply selective adjustments to specific areas of your image to enhance details, draw attention to your subject, etc.
Photo: Tony Sweet
Detail masking allows you to fine tune the painterly look wherever you’d like–such as changing the placement or size of brush strokes, the paint thickness, and more. It makes it simple to enhance or reduce the look in different areas of your image. If you’re working on a portrait for example, you’d want small brush strokes for lots of detail in the face and eyes, and broader strokes in the background to focus attention on your subject.
To apply effects like these to your own images in Snap Art, first select an artistic media preset that complements the image. After making that initial choice, you can customize the effect with the controls in the Background panel. These parameters refine the overall look of the effect. To distort the image a little more, decrease the Photorealism slider. To make the paint strokes more defined, increase the Stroke Length.
To refine specific regions in the image, open the Detail Masking panel. Create a new area and select which adjustment to make from the dropdown list. Before applying any masking, look at the Mask Effect slider values. These numbers illustrate the relationship [arrows] to the same parameters on the background panel. For example, if you decrease one of the sliders here, it will display a negative number; which means it is reducing the value you set on the background panel.
Adjust the masking brush size, feathering, and amount before painting the mask boundaries. You can adjust the size of the mask tool, on the fly, with the bracket keys. Once you make a mask, a small pin will appear on the image in the preview. You can display the mask by hovering the cursor over the pin. If you mask too much switch to the Eraser tool with the minus button and refine the mask boundaries.
WIth the mask complete, take another pass to fine-tune the effects settings. Notice the mask pin. You can only make adjustments to the selected mask–the one that’s black. If a pin is grey, it’s not selected. When using more than one mask, select the mask button to make refinements to each one. To remove the selected mask, use the delete area button.
You can have up to three mask layers in Snap Art, which enables multiple style and detail levels in a single artwork.
You can save the entire look with ⌘+S/Ctrl+S or the plus button at the top of the left-hand pane. Saving a custom preset this way will record the entire effect including any detail masks you made. Saving your settings enables you to easily recreate your favorite looks.
Once you save customized presets, they’re easy to find. Press the user button on the presets pane to see your list of presets. Simply click a preset to apply it. If you’d like to make adjustments to your user presets library, right-click on your preset for more options like delete, edit, and export.

domain: hobby


September saw Aussie markets stumble as China slipped and pushed itself back up, while the whiff of a post-COVID era has some sectors ready for lift-off for the first time in a long time.
Evergrande – the world’s most indebted real estate company – was set to default on its interest payments earlier in the month. Evergrande produce approximately 5% of China’s apartments sold each year and contribute roughly 2% to Chinese GDP; they’re one of the biggest issuers in foreign bond markets, as well as comprising around 10% of all high-yield debt in China. Investors fretted it would be a re-run of the Lehman Brothers in 2008 and the subsequent global financial crisis (GFC). It looks like the company’s been given a chance to redeem itself (while sweating profusely) and the Chinese government has hinted that it’ll be there if everything hits the fan. The world watches with interest, with ripples expected to be felt for weeks or months, whichever way the chips fall.
The RBA announced it would taper bond buying to $4 billion per week (from $5 billion). It’s expected they’ll continue buying at this rate until February, but they have the capacity to increase or decrease before then. RBA head Phillip Lowe also rejected forecasts (from CBA) projecting an interest rate hike next year, instead looking towards 2023 at the earliest. RBA also commented on rising housing prices, which will be affected by the continued low rates, but that’s not part of the RBA remit.
The iron ore price dropped to record lows earlier in the month as China seeks to curb steel output to combat pollution. China currently buys around three quarters of the world’s iron ore. While the iron ore price has since recovered somewhat, iron miners haven’t.
Fortescue Metals (ASX:FMG), our fourth-largest iron or miner, paid out a record $11 billion dividend due to profits from the record high iron ore prices earlier in the year. Compounded with news from the drop in Chinese demand, FMG lost 35% of its share price since the end of August.
Oil price and energy stocks rose due to increased demand from Europe and China. Europe has had a surge in demand after lockdowns were lifted, while China is stockpiling oil for winter, because they had an oil shortage last winter. Hurricane Ida, in the Gulf of Mexico, crippled US oil output, further reducing global oil supply. Global supply chain issues have further created demand-pull inflation, resulting in the soaring price of oil, which should be sustained over the next few months. It’s worth remembering that the price of oil was technically negative earlier in the year, when people had to pay to store it.
Travel stocks have been increasing after announcements about lifting lockdown (QAN +10% FLT +27% WEB +12% in September), with investors expecting domestic flights to resume in October and hoping for international flights by the end of the year. Vaccination rates are playing a big part in this.
Consumer services moved from the fourth most bought sector for September last year to the second most sold this year, while retail sector sales are down for August and expected to be down for September.
It’s worth noting some of the recent comments around the housing market from the International Monetary Fund (IMF), Australian Prudential Regulation Authority (APRA), CBA CEO Matt Comyn and ANZ CEO Shayne Elliott, as well as treasurer Josh Frydenberg – all indications are that there’s likely to be a crackdown on lending, primarily for investor loans.
September and October are traditionally weaker months in the markets, which can see some good buying opportunities leading into the seasonally strong period in December and early January (aka the “Santa Claus rally”). Worth noting that if you bought on Dec 1 and sold on Jan 1 in any of the last 15 years, 80% of the time you’d have made money (but past performance and future returns… well, you know).
Christmas is coming… so we’ll see if Santa delivers. Let’s just hope he’s fully vaxxed.
Hold on a sec! You should consider whether any advice on our website is right for you or your clients. We don’t accept any responsibility for the accuracy any information, opinions, or predictions we’ve provided, and we obviously haven’t taken you or your clients’ personal financial situation into account. Just a heads-up.


text:
|Year : 2023 | Volume
| Issue : 2 | Page : 133-141
Peri-operative antibiotic usage during endourological surgery: A multi-institutional, national-level, cross-sectional audit of prevalent practice pattern in India
Rishi Nayyar1, Shritosh Kumar1, Collaborative Working Group on Use of Antibiotics in Endourology2
1 Department of Urology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||26-Jan-2023|
|Date of Decision||12-Feb-2023|
|Date of Acceptance||16-Mar-2023|
|Date of Web Publication||31-Mar-2023|
Department of Urology, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Antibiotic use during endourological procedures is often discordant from the reported guidelines, despite the potential risks of antibiotic resistance, adverse effects, and health-care costs. A nationwide audit was conducted, with the support of the Urological Society of India, to ascertain the current antibiotic prescription practices for the endourological procedures and the reasons associated with them.
Methods: A multi-institutional, national-level, cross-sectional audit analyzing elective endourological procedures was performed. The data regarding the disease profile; risk factors for infectious complications; urine culture; pre-, per-, and post-operative antibiotic use; additional antibiotic use; and patient demographics were collected in a standardized pro forma. Reasons for prescribing antibiotics divergent from the guideline recommendations were also noted. Any infectious complication that necessitated the antibiotic use was also noted prospectively up to 1 month. All the data were entered into a single centralized and customized online portal on a real-time basis.
Results: One thousand five hundred and thirty-eight cases were recruited from 20 hospitals. A single-dose prophylaxis was prescribed in only 319 (20.7%) of the cases, and the majority received a multi-day prophylaxis. A combination of two or more antibiotics was prescribed as the prophylaxis in 51% of the cases. One thousand three hundred and fifty-six (88.2%) cases were continued on a long-duration prophylaxis after the discharge, with 1191 (77.4%) receiving it for > 3 days. One thousand one hundred and sixty (75.4%) cases received a guideline-discordant prophylaxis solely on the basis of the surgeon's or institution's protocol, rather than any specific case based need. Ninety eight (6.4%) cases developed postoperative urinary tract infection.
Conclusions: Multi-dose, combination and post-discharge antibiotic prophylaxis for endourological surgeries is highly prevalent in India. This audit highlights the huge potential to reduce such guideline-discordant overuse of antibiotics during the endourological procedures.
|How to cite this article:|
Nayyar R, Kumar S, Collaborative Working Group on Use of Antibiotics in Endourology. Peri-operative antibiotic usage during endourological surgery: A multi-institutional, national-level, cross-sectional audit of prevalent practice pattern in India. Indian J Urol 2023;39:133-41
|How to cite this URL:|
Nayyar R, Kumar S, Collaborative Working Group on Use of Antibiotics in Endourology. Peri-operative antibiotic usage during endourological surgery: A multi-institutional, national-level, cross-sectional audit of prevalent practice pattern in India. Indian J Urol [serial online] 2023 [cited 2023 May 30];39:133-41. Available from: https://www.indianjurol.com/text.asp?2023/39/2/133/373129
CWG-UAE (Ajay Anand - Department of Urology, Government Medical College, Jammu, Jammu and Kashmir, India; Arabind Panda - Department of Urology and Renal Transplantation, AIG Hospitals, Hyderabad, Telangana, India; Arun Chawla - Department of Urology, Kasturba Medical College, Manipal, Karnataka, India; Devendra Kumar Sharma - Department of Urology and Renal Transplant, CK Birla Hospital (RBH), Jaipur, Rajasthan, India; Harprit Singh - Department of Urology, Mercy Hospital, Baridih, Jamshedpur, Jharkhand, India; Ishwar Ram Dhayal - Department of Urology and Renal Transplant, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India; Mahendra Singh - Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India; Neeraj Agarwal - Department of Urology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India; Pamposh Raina - Department of Urology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India; P. V. L. N. Murthy - Department of Urology, Kamineni Institute of Medical Sciences, Narketpally, Telangana, India; Ramesh D - Department of Urology, Ramaiah Medical College, Ramaiah University of Applied Sciences, Bangalore, Karnataka, India; Sameer Trivedi - Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India; T Srikala Prasad - Department of Urology, Government Medical College, Chengalpattu, Tamil Nadu, India; Stephen Lalfakzuala Sailo - Department of Urology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India; Sudheer K Devana - Department of Urology, Post-Graduate Institute of Medical Education and Research, Chandigarh, India; Sujata Patwardhan - Department of Urology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India; Vijay Madduri - Department of Urology, Asian Institute of Nephrology and Urology, Hyderabad, Telangana, India; Vikas Kumar Panwar - Department of Urology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India)
| Introduction|| |
Antibiotic prescription protocols for the endourological procedures varies across the hospitals in India, despite the availability of a multitude of guidelines recommending a single-dose prophylaxis for the most of the endourological procedures.,,, Several factors contribute to this non-adherence to the guidelines including the apprehension of sepsis, a lack of available data and guidelines from the Indian patients, and unique surgical factors such as endourological flora, use of irrigation fluid, stents, and catheters. Antibiotics are over prescribed in up to 50% of the patients undergoing common urological procedures. Evidence suggests that an overuse, beyond the standard recommendation, not only promotes antibiotic resistance and adds to the cost but also exposes the patient to an increased risk of other infections.
This nation-wide audit was conducted with the support of the Urological Society of India (USI), with an aim to document the current antibiotic prescription patterns for the common endourological procedures (cystoscopy, transurethral resection of prostate [TURP], transurethral resection of bladder tumor [TURBT], ureteroscopy [URS], and percutaneous nephrolithotomy [PCNL]). The secondary objectives were to evaluate the factors that drive the antibiotic prescription and to evaluate the incidence of perioperative infections. Such data are a step towards antibiotic stewardship and shall also serve as a baseline to prepare the region-specific guidelines.
| Materials and Methods|| |
A multi-institutional, national-level, cross-sectional audit was undertaken from April to July 2022. Any urological center with a qualified urologist performing ≥30 endourology cases over a period of 3 months was eligible to enroll. The audit was primarily approved through the local ethics committee vide IEC-812/2021, and then subsequently approved at the each individual participating center.
All consecutive cases of elective cystoscopy, TURP, TURBT, URS, or PCNL were eligible for inclusion. Exclusion criteria included any complication during the surgery requiring the use of means other than the endourological methods; immune-deficiency disorder; cardiac valve implant or risk of infective endocarditis; neurourological diseases necessitating the use of catheters; and, bilateral upper tract procedure. Data regarding the pre-, per-, and post-operative antibiotic use, patient demographics, and the disease profile were collected in a standardized pro forma. The use of any antibiotic, beyond a single perioperative prophylactic dose, was noted along with the reasons for the same. Any infectious complication (febrile illness, pyelonephritis, genital infection, sepsis, and intensive care unit [ICU] admission) requiring the use of antibiotics was prospectively recorded up to 1 month after the surgery and was taken as a surrogate definition of clinical post-operative urinary tract infection (UTI). All the data were entered onto a single centralized and customized online portal on a real-time basis.
Descriptive analysis was performed for the demographic and clinical data. The groups with and without infection were compared using the Chi-square analysis for the categorical variables, and the Fisher's exact test was used if the cell values were <5, whereas the one-way ANOVA was utilized for the continuous variables. All the statistical analyses were performed using the Statistical Package for Social Scientists version 25.0 (SPSS Inc., Chicago, IL, United States).
| Results|| |
Twenty hospitals across India participated in the study, including 10 from North, 6 from South, 3 from East, and 1 from West Zone as per the USI jurisdiction. Thirteen were government teaching hospitals, 5 were private teaching hospitals, 1 was corporate hospital, and 1 was a single surgeon center. One thousand five hundred and thirty-eight cases were recruited, with an average of 77 ± 71 (range: 6–315) cases per center. Six hundred ninety-eight, 694, 121, and 25 cases were from North, South, East, and West zones, respectively [Table 1]. These were performed by 36 surgeons with a postdoctoral practice experience of <5, 5–15 and >15 years in 9, 13, and 14 surgeons, respectively. Patient demographics, procedure, and preoperative culture details are provided in [Table 2]. PCNL and URS constituted 65.1% of the cases.
|Table 1: Distribution of surgical cases across different geographical zones as per the jurisdiction of Urological Society of India|
Click here to view
Preoperative culture and urinary tract infection
Urine culture within 1 week of the surgery was not available for 19.3% of the patients. Two hundred (13%) cases had significant bacterial counts (>105 cfu/ml) on the urine culture. Escherichia coli (59%) and Klebsiella spp. (19.5%) were the most common organisms isolated from the positive cultures.
Overall, postoperative UTI requiring additional antibiotic (s) was reported in 98 (6.4%) cases. The rate of UTI was 10.5% (21/200), if the preoperative culture was positive. Detailed results regarding the rate of UTI stratified as per the procedure and the antibiotic prophylaxis are provided in [Table 3].
|Table 3: Post-operative urinary tract infection rates (as defined by use of antibiotic for clinical urinary tract infection/sepsis within 1 month of procedure) distributed according to various demographic parameters (univariate analysis)|
Click here to view
Preoperative antibiotic use and urinary tract infection
Two hundred cases had a history of antibiotic use within 3 months of the surgery. Two hundred and seventy-four patients were treated with antibiotics immediately preceding the surgery. [Table 4] indicates the practice patterns for antibiotic use vis-à-vis urine culture. The rate of UTI was significantly higher in the cases where preoperative antibiotics were administered. Twenty-seven different antibiotics were prescribed and piperacillin + tazobactam was the most common (in 44 cases). Other high-end antibiotics such as cefoperazone + sulbactam, cefixime + clavulanate, cefpodoxime + clavulanate, ceftazidime + tazobactam, ceftazidime + avibactam, ertapenem, faropenem, imipenem, meropenem, and vancomycin were prescribed in additional 112 cases. Preoperative antibiotics were prescribed for a median of 3.5 (mode: 1, range: 1 - >10) days. In 200/274 (73%) cases, the same antibiotic was continued as the peroperative prophylaxis.
|Table 4: Practice pattern for antibiotic use before the surgery, based on urine culture and corresponding UTI rates|
Click here to view
The proportion of Pseudomonas, Klebsiella and Proteus spp. taken collectively as the cultured bacteria in the groups with insignificant and significant bacterial counts was 4/28 and 61/200, respectively. After censoring the data of cases that grew these strongly uropathogenic bacteria, the rate of UTI was still consistently higher in those who received the preoperative antibiotics [Table 4].
Peroperative antibiotic use and urinary tract infection
98.3% of the patients were prescribed peroperative prophylaxis. Cefoperazone + sulbactam (41%) was the most common antibiotic followed by ceftriaxone (26%) and piperacillin + tazobactam (8%). A single dose was prescribed in 319 (20.7%) cases, and the other prescribed protocols were 1, 2, 3, or ≥3 days in 20.1%, 18.4%, 24.1%, and 10.9% patients, respectively. An additional antibiotic was prescribed in 788 (51.2%) of the cases. Amikacin was the most common second antibiotic and was prescribed in 693 (45.1%) and was most frequently (26.5%) prescribed as a single dose. However, this additional antibiotic was also continued for 1, 2, 3, or >3 days in 51 (3.3%), 84 (5.5%), 160 (10.4%), and 48 (3.1%) cases, respectively.
Postoperative UTI rates were significantly lower in the patients who received a short duration (1, 2 or 3 days) of per-operative prophylaxis as compared to those who received a single-dose antibiotic [Table 3]. However, when compared with the cases who received >3 days' prophylaxis, the difference was not significant.
Postoperative antibiotic use and urinary tract infection
One thousand three hundred and fifty-six (88.2%) patients were prescribed antibiotics as continued prophylaxis on discharge. For this purpose, oral cephalosporins with or without beta-lactamase inhibitors were the most commonly prescribed antibiotics in 855 (55.6%) followed by fluoroquinolones in 325 (21.1%) and faropenem in 110 (7.1%) cases. 1191 (77.4%) cases received such prophylaxis for > 3 days' duration. The presence of comorbidity or any other predisposing risk factor was not the reason for such a prophylaxis, since 55.1% of the patients who underwent cystoscopy, 26.2% of the TURBT, 30.5% of the TURP, 50.3% of the URS, and 31.9% of the patients who underwent PCNL had no underlying pre-, per- or post-operative predisposing risk factor, by the strictest definition [Supplementary Table 1].
Reasons for antibiotic use other than single-dose prophylaxis
One thousand one hundred and sixty (75.4%) cases received more than the recommended single dose of prophylaxis solely on the basis of surgeon's or institution's protocol. The presence of postoperative stent or nephrostomy was considered as a significant factor for the continued prophylaxis in 191 (12.4%) cases, while it was considered as the sole factor in only 46 (3%) of these. Suboptimal surgical asepsis or self-cleanliness were the reasons in a minority. Two hundred and seventy-six (17.9%) cases received more than a single-dose of prophylaxis based on multiple (>1) factors. Details of the type and the duration of antibiotic use are provided in [Supplementary Table 2].
Individual procedures and the preoperative, intraoperative, and postoperative detailed data, is shown in [Supplementary Table 1] and [Supplementary Table 2].
| Discussion|| |
Multiple factors such as the exposure to Gram-negative Enterobacteriaceae; fluid irrigation with the risk of pyelo-venous or pyelo-lymphatic backflow; and, the use of stents, catheters, or nephrostomy before and after the surgery make endourological procedures unique and different from the other surgeries. Hence, the general recommendations for surgical site infections are not directly applicable to the endourological surgeries. However, this lack of applicability has also resulted in the unbridled use of antibiotics for all the endourological surgeries.
Wide variability in the type, duration, and the dose of antibiotics for perioperative prophylaxis has made it difficult to firmly establish its utility. The patient's limited benefit has to be balanced against the adverse drug reactions and serious hazards of antibiotic resistance as well as the health-care costs. Principles of antibiotic prophylaxis necessitate it to be a narrow-spectrum antibiotic being able to prevent infections according to the local antibiogram rather than being a broad-spectrum antibiotic and the second-generation cephalosporin is the most commonly recommended antibiotic across the guidelines.,2], Cystoscopy has been categorized as low risk, TURBT and URS as intermediate risk, and TURP and PCNL as high risk for postoperative UTI. Most guidelines strongly recommend a “no use” policy for antibiotics for cystoscopy or TURBT and only a single-dose of prophylaxis for all the other endourological procedures, based on a high-level evidence., However, as we found out, the real-life practice is vastly aberrant and almost all the patients were prescribed prophylactic antibiotics and 972 (63.2%) were prescribed a high-end antibiotic (penicillins/cephalosporins with beta-lactamase inhibitors or carbapenems) as the per-operative prophylaxis. More importantly, such a prophylaxis was continued for several days in 73% of the patients and was combined with an additional antibiotic in 51% of them. This additional antibiotic was also continued for several days in as many as 22.3% of the cases, emphasising on the huge unmet need of curtailing the antibiotic use in endourological surgeries, particularly because this practice was primarily driven by the surgeon's or the institution's protocols in more than 75% of the cases, rather than any pressing patient related need.
Preoperative antibiotic use is even more contentious since most of the trials exclude the cases with a positive culture. Many studies suggest that a positive urine culture is a risk factor for UTI., However, this risk predisposition has resulted in an assumption that one should achieve a sterile urine status with antibiotics prior to the surgery, as a good clinical practice, without high quality data supporting it. On the contrary, some recent evidence suggests that preoperative antibiotic use, despite reducing the bacteriuria, is an independent risk factor for systemic inflammatory response syndrome (SIRS) and the risk remains high even if one follows a strategy of prolonged preoperative culture-directed antibiotics and confirms a sterile urine on the repeat culture.,, A sterile urinary tract status is more of an assumption than a reality as the uropathogens can be demonstrated in the urinary tract using more potent methods, even when the urine culture is sterile by the standard methods. Stones and biofilms also harbor bacteria shielded from the impact of antibiotics which may get released into the urinary tract during the surgery. The rate of SIRS has also been shown to remain high, despite the intensive perioperative prophylaxis, in cases with a positive urine culture as compared to those with a negative culture. Furthermore, at present, there are no data to suggest that a single dose, 1, 3-, or a 5-day therapy is superior over the other in this setting. Therefore, the use of preoperative antibiotics, with the sole intention of achieving a sterile urine status prior to surgery requires further rigorous evaluation before it can be recommended as a standard policy. Currently, such an approach remains highly driven by the institution's or the individual's perception bias rather than the scientific evidence. We found that the practice patterns of treating the preoperative asymptomatic bacteriuria is highly variable with as many as 30.5% of the cases being prescribed no preoperative antibiotic. Interestingly, a significantly higher rate of UTI was noted in patients who received preoperative antibiotics as compared to those who did not, irrespective of whether the preoperative culture was mixed, insignificant growth, or significant growth. A post hoc power analysis showed a 62.3% power keeping the alpha error at 0.05, for this finding. While one may argue for the impact of confounders such as hydronephrosis, comorbidities, type of instruments, sterilization methods, and external tubes on this finding, a higher UTI rate was consistently found across all the individual procedure types as well [Table 2]. This important finding raises a strong doubt on the general practice of treating preoperative asymptomatic bacteriuria prior to all the types of endourological procedures, pending specifically designed studies. Prolonged antibiotic use may also select out more resistant bacteria, alter the normal microbiome of the urinary tract, and predispose to fungal infections, besides its side effects.
Antibiotics after the discharge is another major component of antibiotic use that remains in vogue despite no scientific evidence to suggest its efficacy. An overwhelming 88.2% of the cases received antibiotics at discharge, with 77.4% receiving it for >3 days' duration, clearly indicating overuse, since such a practice is not recommended by any of the guidelines. A recent meta-analysis comparing single versus extended (pre- or post-operative) doses of antibiotics after PCNL did not find an overall difference in the rate of postoperative fever or SIRS. However, considering only the high-risk cases (large stone burden, hydronephrosis, history of UTI, and infected staghorn stone), extended antibiotic use was associated with a lower rate of SIRS when compared to a single dose antibiotic (P < 0.0001, odds ratio = 3.53). On a broader view, these high-risk cases comprised only 27.7% (337/1218) of the cases in this meta-analysis. Further, the heterogeneity of data in the terms of defining high-risk and the type or duration of extended antibiotic use makes it difficult to apply these findings to the general population. Nonetheless, the prevalent practice of aggressive antibiotic use over prolonged periods in post-discharge settings, especially when the majority are low-risk cases, warrants a change. Such a use should be highly discouraged and a policy of “No antibiotic prescription” at the discharge should be firmly adopted unless absolutely indicated.
Cystoscopy has < 5% risk of symptomatic UTI and < 2% risk of systemic UTI as per a recent Cochrane review. Therefore, the potential marginal benefit to be gained by the routine use of prophylactic antibiotics prior to cystoscopy is highly questionable. Many randomized trials show a similar rate of systemic UTI with or without antibiotic prophylaxis,, however, on the other hand, there is significant risk of new-onset bacterial resistance (Risk Ratio =1.73 [1.04–2.87], P = 0.03) with the use of antibiotic prophylaxis. Hence, the guidelines discourage prophylactic antibiotics for cystoscopy. Our audit also did not find a significant difference in the rate of 30-day postprocedure UTI after cystoscopy. As discussed previously, preoperative antibiotics prescribed to treat asymptomatic bacteriuria based on the urine culture reports, were found to be detrimental with significantly higher chances of UTI in those who received them. This finding corroborates with the recent evidence from other well-conducted clinical studies and calls for a radical change in the antibiotic prophylaxis protocol for cystoscopy, regardless of the presence of predisposing factors for the development of infection.
TURBT as a procedure is more invasive than diagnostic cystoscopy. However, similar to cystoscopy, prophylactic antibiotics have not been shown to improve the postoperative UTI rates. The use of antibiotic prophylaxis is controversial even in the presence of presumed risk factors, because none of the risk factors (such as age >75 years, indwelling catheter, past pelvic radiotherapy, preoperative hospitalization, positive culture, pyuria, or tumor size) have been consistently shown to predict post-operative UTI across all the studies. We also did not find a difference in the rate of UTI between the different durations of prophylaxis used for TURBT. The cohort that received preoperative antibiotic had a higher incidence of UTI, emphasising that the practice of treating asymptomatic bacteriuria prior to TURBT should be strongly discouraged.
The results for URS and PCNL were similar to those for cystoscopy and TURBT in our audit. The rate of UTI was similar between those who received a single versus more than a single dose of prophylaxis. On the contrary, preoperative antibiotic use was associated with higher postoperative UTI rates. As discussed previously, in a recent meta-analysis, extended prophylaxis was not superior to the standard one when comparing the rate of postoperative fever or SIRS in the patients undergoing PCNL. Potretzke et al. evaluated high risk patients (history of previous UTI, hydronephrosis, or stone size ≥2 cm) with sterile urine culture undergoing PCNL under a 7 days, 2 days, or no preoperative antibiotic prophylaxis and found no difference in the rate of SIRS. The rate of SIRS remains high in cases with positive urine culture, as compared to those with negative urine cultures, despite intensive perioperative prophylaxis. Similarly for URS, several studies have demonstrated that preoperative antibiotic use does not reduce the postoperative UTI and fever rates and continued prophylaxis after the discharge does not improve the 30-day UTI rate (2.9% vs. 3.6%, P = 0.5).,
Unlike the other groups in our audit, more than a single-dose antibiotic prophylaxis (5.1% vs. 16.1%, P = 0.005) was associated with a reduced rate of UTI in the TURP cohort. This discrepancy may be explained by the high prevalence of risk factors such as the presence of indwelling catheter (59%) and previous UTI (23%). In a systematic review published in 2009, the use of prophylactic antibiotics resulted in a relative risk reduction by 0.51 (confidence intervals: 0.27–0.96) for sepsis when compared to a placebo. However, the absolute risk reduction was only 2% (3.4%–1.4%), and the number needed to treat was 50. Similar to the other surgical groups, TURP group also showed a significantly increased risk of UTI with the use of preoperative antibiotics. This trend was consistent across all the types of endourological surgeries.
The unnecessary, excessive, and guideline-discordant use of antibiotics is a global phenomenon, and needs concerted efforts at a global level. It is our view, that medico-legal implications on the account of UTI/sepsis may be a major factor driving such an irrational use, as systemic sepsis occurs in a minority and is salvageable with minimal sequelae in the majority., Suboptimal surgical asepsis including instrument sterilization/disinfection was reported as a reason for excess antibiotic use in only 9/1538 cases. Most available studies, guidelines, and reviews are also cognizant of the practice of high-level disinfection of the equipment as against the preferred sterilization.,,,, Thus, developing a predictive factor-based strategy is the need of the hour. Auditing the practice patterns, identifying the reasons for excess use, and a focused redressal of these reasons, besides well-conducted clinical studies on the topic, is the only way forward to overcome this menace. Guidelines with due clarity regarding the use of antibiotics in pre-, per-, and post-operative settings, spreading awareness about stewardship, recommending insurance reimbursement for only a single-dose prophylaxis, ensuring antibiotic stewardship as an essential component for hospital accreditation, are the other possible steps in this direction. Till then, it would be helpful to understand the concept of prophylaxis as the prescription of a single dose lower end antibiotic, unless strongly indicated otherwise, and that the antibiotic prophylaxis at the discharge after an uneventful surgery should be discontinued.
The main strengths of this audit are prospective data collection, large response rate, and inclusion of all kinds of cases irrespective of the urine culture status or antibiotic regime. There are a few limitations of this audit as well. First, the data accrual and the distribution of the type of surgery were not uniform across all the zones. Second, it could not be firmly confirmed if all the consecutive cases were enrolled or not, which may induce a sampling bias in the representation of a true real-world situation. However, the finding of a very high per- and post-operative antibiotic usage, across all the types of surgeries, negates its possible impact on the assessment of the real-world situation to a large extent. Third, we do not know whether the preoperative antibiotic administration was coupled with a repeat urine culture and the documentation of a sterile urine status or not. Fourthly, we have not looked at the side effects and the cost-benefit analysis of antibiotic use, which is also an important clinical aspect with an impact on the practice patterns. Fifth, the definition of postoperative UTI defined as the “use of antibiotics” as a surrogate may not reflect the true UTI rates, as these patients may often have stent-related symptoms or noninfective inflammation/fever which may be incorrectly treated with antibiotics irrespective of the culture report. However, this definition more closely reflects the real-world practice for the purpose of an audit on the antibiotic use. Sixthly, we do not have the data on the temporal relation between postoperative UTI and prophylaxis. Finally, whether the postoperative UTI lead to sepsis and ICU admission or not remains unknown and may be an important benchmark to compare between the different antibiotic practices since febrile UTIs can be treated with a salvage antibiotic treatment in an overwhelming majority of the cases.
| Conclusions|| |
Overall, our audit showed that the use of antibiotics as multi-dose, combination, and postdischarge prophylaxis for endourological procedures is highly prevalent in India. Such a use is discordant with the available scientific evidence or guideline recommendations. While there is still a long way to go before standardized antibiotic regimen (s) could be recommended, there is a huge potential to reduce the overuse of antibiotics during these procedures.
- USI for providing technical and financial support for developing data repository and spreading information to help improve participation
- USI Collaborative research committee for helping in peer-review of protocol development and publications
- All members of the collaborative working group on the use of antibiotics in endourology contributed equally to case recruitment and data generation with equal authorship contribution among themselves.
Financial support and sponsorship: Nil.
Conflicts of interest: There are no conflicts of interest.
| References|| |
Lightner DJ, Wymer K, Sanchez J, Kavoussi L. Best practice statement on urologic procedures and antimicrobial prophylaxis. J Urol 2020;203:351-6.
National Institute for Health and Care Excellence (NICE). Surgical Site Infections: Prevention and Treatment. London: National Institute for Health and Care Excellence (NICE); 2020. Available from: https://www.nice.org.uk/guidance/ng125/
. Accessed: 8th
Bonkat G, Bartoletti R, Bruyère F, Cai T, Gerling's SE, Köves B, et al
. EAU Guidelines on Urological Infections. Presented at the EAU Annual Congress Amsterdam, the Netherlands. Arnhem, the Netherlands: EAU Guidelines Office; 2022. ISBN 978-94-92671-16-5.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al.
Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195-283.
Khaw C, Oberle AD, Lund BC, Egge J, Heintz BH, Erickson BA, et al.
Assessment of guideline discordance with antimicrobial prophylaxis best practices for common urologic procedures. JAMA Netw Open 2018;1:e186248.
Bhojani N, Miller LE, Bhattacharyya S, Cutone B, Chew BH. Risk factors for urosepsis after ureteroscopy for stone disease: A systematic review with meta-analysis. J Endourol 2021;35:991-1000.
Tang Y, Zhang C, Mo C, Gui C, Luo J, Wu R. Predictive model for systemic infection after percutaneous nephrolithotomy and related factors analysis. Front Surg 2021;8:696463.
Liu J, Zhou C, Gao W, Huang H, Jiang X, Zhang D. Does preoperative urine culture still play a role in predicting post-PCNL SIRS? A retrospective cohort study. Urolithiasis 2020;48:251-6.
Xu P, Zhang S, Zhang Y, Zeng T, Chen D, Wu W, et al.
Enhanced antibiotic treatment based on positive urine dipstick infection test before percutaneous nephrolithotomy did not prevent postoperative infection in patients with negative urine culture. J Endourol 2021;35:1743-9.
Chavarriaga J, Villanueva J, Varela D, Erazo S, Usubillaga MC, Erazo JC, et al.
Do we need a urine culture before cystoscopy? Time to shift away from routine testing. Urology 2023;172:13-7.
Nayyar R, Dadhwal R, Kapil A, Pandey RM, Dogra P. Urethral instillation of povidone-iodine reduces post-cystoscopy urinary tract infection in males: A randomized controlled trial. Sci Rep 2020;10:3585.
Walton-Diaz A, Vinay JI, Barahona J, Daels P, González M, Hidalgo JP, et al.
Concordance of renal stone culture: PMUC, RPUC, RSC and post-PCNL sepsis-a non-randomized prospective observation cohort study. Int Urol Nephrol 2017;49:31-5.
Jung HD, Cho KS, Moon YJ, Chung DY, Kang DH, Lee JY. Antibiotic prophylaxis for percutaneous nephrolithotomy: An updated systematic review and meta-analysis. PLoS One 2022;17:e0267233.
Zeng S, Zhang Z, Bai Y, Sun Y, Xu C. Antimicrobial agents for preventing urinary tract infections in adults undergoing cystoscopy. Cochrane Database Syst Rev 2019;2:CD012305.
Bausch K, Halbeisen FS, Aghlmandi S, Sutter SU, Ewald H, Appenzeller-Herzog C, et al.
Antimicrobial prophylaxis for postoperative urinary tract infections in transurethral resection of bladder tumors: A systematic review and meta-analysis. J Urol 2021;205:987-98.
Potretzke AM, Park AM, Bauman TM, Larson JA, Vetter JM, Benway BM, et al.
Is extended preoperative antibiotic prophylaxis for high-risk patients necessary before percutaneous nephrolithotomy? Investig Clin Urol 2016;57:417-23.
Martov A, Gravas S, Etemadian M, Unsal A, Barusso G, D'Addessi A, et al.
Postoperative infection rates in patients with a negative baseline urine culture undergoing ureteroscopic stone removal: A matched case-control analysis on antibiotic prophylaxis from the CROES URS global study. J Endourol 2015;29:171-80.
Greene DJ, Gill BC, Hinck B, Nyame YA, Almassi N, Krishnamurthi V, et al
. American Urological Association antibiotic best practice statement and ureteroscopy: Does antibiotic stewardship help? J Endourol 2018;32:283-8.
Wollin DA, Joyce AD, Gupta M, Wong MY, Laguna P, Gravas S, et al.
Antibiotic use and the prevention and management of infectious complications in stone disease. World J Urol 2017;35:1369-79.
Dahm P, Dmochowski RR. Evidence-Based Urology. London: BMJ Books; 2010. p. 50. ISBN: 978-1-4051-8594-3.
Zhang S, Li G, Qiao L, Lai D, He Z, An L, et al.
The antibiotic strategies during percutaneous nephrolithotomy in China revealed the gap between the reality and the urological guidelines. BMC Urol 2022;22:136.
Gutierrez J, Smith A, Geavlete P, Shah H, Kural AR, de Sio M, et al.
Urinary tract infections and post-operative fever in percutaneous nephrolithotomy. World J Urol 2013;31:1135-40.
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Use of the quick sequential organ failure assessment score for prediction of intensive care unit admission due to septic shock after percutaneous nephrolithotomy: A multicenter study. J Urol 2019;202:314-8.
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Zhou G, Zhou Y, Chen R, Wang D, Zhou S, Zhong J, et al.
The influencing factors of infectious complications after percutaneous nephrolithotomy: A systematic review and meta-analysis. Urolithiasis 2022;51:17.
[Table 1], [Table 2], [Table 3], [Table 4]

domain: medical


text:
Stinson advised CrossFirst Bankshares Inc. on the deal.
CrossFirst Bankshares Inc., based in Leawood, Kansas, announced it has entered into an agreement in which its bank subsidiary, CrossFirst Bank, will acquire Farmers & Stockmens Bank. The transaction is expected to close in the second half of 2022.
The transaction will widen the scope of the CrossFirst franchise, with existing banking locations in Kansas, Oklahoma, Texas, Missouri, and Arizona, and adding in the Denver, Colorado Springs and New Mexico branches of Farmers & Stockmens Bank.
Stinson attorneys involved in the matter include Scott Gootee (Picture), Greg Johnson and Bob Monroe.
Law Firms: Stinson LLP;
Clients: CrossFirst Bankshares;

domain: finance


A vulnerability has been identified in SIMATIC ET 200SP Open Controller (All versions >= V2.0), SIMATIC S7-1500 Software Controller (All versions >= V2.0 and < V2.5), SIMATIC S7-1500 incl. F (All versions >= V2.0 and < V2.5). An attacker can cause a denial-of-service condition on the network stack by sending a large number of specially crafted packets to the PLC. The PLC will lose its ability to communicate over the network. This vulnerability could be exploited by an attacker with network access to the affected systems. Successful exploitation requires no privileges and no user interaction. An attacker could use this vulnerability to compromise availability of the network connectivity.


Kyosei Kamitsuki Gattai SpinoDai-Oh is the combination of the Zyudenryu; Tobaspino, Ankydon, and Bunpachy and was exclusively featured in the Zyuden Sentai Kyoryuger: Gaburincho of Music until its later appearance in the episode 39. SpinoDai-Oh was the primary robo piloted by the main antagonist, Deathryuger but is later piloted by the Kyoryugers, summoned by the call of "Kamitsuki Gattai." While the mecha is armed with Ankydon Hammer and Bunpachy Ball, the SpinoDai-Oh is primary armed with Spino Boomerang and the Spino Defenser. SpinoDai-Oh's finishing attack is the Spinodai-Oh Brave Finish, where it charges Brave Energy into the Spino Boomerang, which is then thrown at the target, shredding it as it flies. While under the control of the evil Deathryuger, SpinoDai-Oh created a Super Destroying Light Bullet, an energy ball shot out from the Spino Head cannon, fueled by Mikoto Amano's life force, and had it been unleashed, mass destruction would have followed. It was destroyed when SpinoDai-Oh went inside the energy ball and destroyed it with the Spinodai-Oh Brave Finish, where SpinoDai-Oh spun like a top, with the Ankydon Hammer and Bunpachy Ball out at full force.
SpinoDai-Oh Western is the combination of Tobaspino, Parasagun, and Zakutor. Its finishing attack is the SpinoDai-Oh Western Brave Finish, where it creates an orb which is shot from the Parasa Beam Gun before locking the opponent inside the enlarged orb and performing a slashing attack with the Zakutor Sword.


text:
Diamond Sofa Casablanca Top Grain Leather Loveseat
Good deals! Buy with discount. If you would like to order now. Please check the product's features. And compare prices before deciding to buy this loveseat.
Bring harmony to your home by adding the Casablanca collection from Diamond Sofa. Its ultra modern folded design lends modern flair to your space. Sumptuous white leather in the perfect shade with plush arm and back pillows bring comfort home. A kiln-dried, solid wood frame, quality innersprings, and plush cushions ensure lasting comfort that gives you something to sing about. Genuine white leather lines the interior with match on outsides and back Overstuffed arm design Unique angled metal leg Two over two design Hardwood frame Casablanca collection Lifetime warranty
My best friend's birthday is coming up, so of course I was browsing shopping website for her gift. After seeing these loveseat, I knew that I had found the perfect gift. is good quality. Great buys!
Three Videos for Home Furniture Shopping Online
HOME DECOR & FURNITURE SHOPPING SPREE!
Great loveseat! Love the material and fit! Will buy in other colors too! I love this . I bought the black first and then I ordered the target. I love the fit, too. I can buy another color later if it is still available.
Fast shipping. loveseat exceeded my expectations. The color is great. I have had it for a week and received so many compliments. I love. Overall a great buy for its price. The quality of the loveseat is excellent.
I was looking for a gift to send someone on a secret Santa exchange and as soon as I saw this I knew it would be perfect! So cute! Simple and elegant. I bought one for myself and a friend and she loved it.
Diamond Sofa Casablanca Top Grain Leather Loveseat Review by Anonymous users

domain: design


The cutoff frequency f//t and maximum frequency of oscillation f//m //a //x of the permeable base transistor have been calculated using a drift-diffusion model, for GaAs and InP devices with a fixed geometry and different doping profiles and different static velocity-field curves. The uniformly doped device, N//d equals 4 multiplied by 10**1 **6 cm-**3 , has a higher f//m //a //x when the saturated velocity is larger, but the effect of the low field mobility is small. The InP device has a slightly higher f//m //a //x than the corresponding GaAs devices at this doping level. The uniform 10**1 **7 cm-**3 device, the 4-10-4 multiplied by 10**1 **6 cm- device, and the 20-10-4 multiplied by 10**1 **6 cm-**3 device have the highest f//m //a //x of all the GaAs devices investigated.
|Original language||English (US)|
|Title of host publication||Unknown Host Publication Title|
|Number of pages||10|
|State||Published - Dec 1 1985|


text:
More than 900 goldsmiths and jewellery designers from around 70 countries have applied to display their work at the special exhibition for contemporary jewellery. This takes place at “Handwerk & Design” as part of the International Craft Trades Fair at the Fairground Munich every year. From the 7th to 13th March 2018, visitors will be able to admire the creations of 65 jewellery designers from 21 countries at Schmuck.
This year the participants were selected by Hans Stofer, Head of Jewellery Department at the Burg Giebichenstein University of Art and Design Halle. “What amazed me again and again as I looked at the submitted portfolios spread on the table and each individual portfolio that I picked up was the endless diversity of jewellery-making presented,” he said about the selection process. In the end, works from 65 artists in 21 countries were chosen. Germany has the strongest presence, followed by Japan, Argentina, and the Netherlands. On Saturday, 10th March 2018, 5 p.m. the prestigious Herbert Hofmann Prizes will be awarded on the stage in Hall B1 of the International Craft Trades Fair.
In addition a “Modern Classic” is also honoured with a retrospective every year. In 2018, this will be Otto Künzli from Switzerland, artist and former Professor at the Academy of Fine Arts Munich. “His excellent role,” justifies the jury, “has played a decisive part in the City of Munich being regarded as a centre of contemporary jewellery throughout the world – a phenomenon that is reflected at the special jewellery exhibition of the International Craft Trades Fair year in year out.”
For several years, the appearances of international galleries at the Craft Trades Fair under the title “Frame” has also contributed to this recognition. In 2018, the following nine galleries will attend: Platina (Sweden), Ra Gallery Amsterdam (Netherlands), Marzee Gallery (Netherlands), Gallery Rosemarie Jäger (Germany), ATTA Gallery (Thailand), Galerie Spektrum (Germany), NZ Makers (New Zealand, continuation of the Handshake art project), Tactile Gallery (Switzerland), Galerie Biro (Germany), and Chrome Yellow Books (United Kingdom).
For Schmuck 2018, the trade show organisation GHM will organise a separate city map showing all events in the galleries, lofts, and museums, which are also taking place to celebrate the special show in Munich. In addition to information on Schmuck and “Handwerk & Design” within the scope of the Craft Trades Fair, this will include further event locations and dates. The printed city map can be obtained at the trade show, while an online version will be available at www.ihm-handwerk-design.com from February 2018.
About “Handwerk & Design” [Craft and Design]
As part of the Internationale Handwerksmesse [Craft Trades Fair] the “Handwerk & Design” arose in 2008. The idea behind it was to combine outstanding performances in crafts, art handicrafts and design at the Internationale Handwerksmesse. During the Internationale Handwerksmesse, everything is about the incorporation of craftsmanship and good design in hall B1 on the fairground Messe München. The «handwerk & design» is made up of numerous special shows such as Exempla, Schmuck, Talente or Meister der Moderne. Unfortunately, even after many years, the International Crafts Fair has not succeeded in keeping Hall B1 free from exhibitors who are not characterized by their good design or excellent craftsmanship.
Internationale Handwerksmesse München
Craft Trades Fair Munich

domain: artistic


text:
Good morning to you, are you enjoying the fab new release stamps from Crafty Sentiments Designs, they will be available to buy from tomorrow and I'll be back shortly to share my preview of the new release but until then let me tell you all about the new challenge over at Crafty Sentiments and this time we'd like you to celebrate 'Christmas in September' with us. The prize this week is this adorable stamp ...
For my card I have used 'Christmas Seasons' from the recent new release and coloured her with copics and spectrum pens & pencils, I was trying for a more muted vintagey feel to the card and colours, hope I achieved it. Papers are Bo Bunny and I have over stamped the bottom layer with a festive foliage stamp in a similar colour, the sentiment is also cut from a piece of the papers, finished off with some poinsettia die cuts with glittered dots in the middle and then a few green gems.
I would like to enter this card into the following challenges:
Crafty Creations #272 ~ Vintage
OSAAT #220 ~ Anything goes with flowers
Incy Wincy Designs ~ Anything Goes


text:
…7 even though I have received such wonderful revelations from God. So to keep me from becoming proud, I was given a thorn in my flesh, a messenger from Satan to torment me and keep me from becoming proud. 8 Three different times I begged the Lord to take it away. 9 Each time he said, “My grace is all you need. My power works best in weakness.” So now I am glad to boast about my weaknesses, so that the power of Christ can work through me. 10 That’s why I take pleasure in my weaknesses, and in the insults, hardships, persecutions, and troubles that I suffer for Christ. For when I am weak, then I am strong. – 2 Corinthians 12:7-9 (NLT)
God did not promise us to have a trial-free, worry-free, hardship-free, trouble-free, insult-free or any other <unpleasant-thing>-free life. If God did this, we have the tendency to become proud and even neglect him.
But one best thing God has for us, His grace. His power works best for our weaknesses. And through God, we become strong and able to win over the weaknesses that we have.

domain: literature


text:
When you apply for a home loan the lender will want to see two years of employment history. The lenders require this because they want to originate loans that will perform over a long time. When you have a gap of employment longer than six months, this usually is a red-flag to a lender. If you hop around from job to job it can be even more difficult as […]
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By submitting this form, you authorize Bank of America to contact you at the telephone number or email provided here, even if you’ve previously registered on a Do Not Call registry or requested that we not send you marketing information by email. You agree we may use an auto-dialer to reach you. You understand that you are not required to consent to receiving autodialed calls/texts as a condition of purchasing any Bank of America products or services. Any cellular/mobile telephone number you provide may incur charges from your mobile service provider.
You can find a lender on Zillow to learn how much you can borrow. And you can use Zillow’s affordability calculator to estimate what you can afford. But you should go a step further and figure out what you can be comfortable with. Is travel a passion? Do you like spending a fair amount on dining out or other entertainment? The lender won’t factor biannual vacations or a craving for high-end restaurants into their calculations, so you have to. Fortunately, that’s easy enough with tools that help you calculate your monthly payment as well as estimate what you should be able to afford given your existing income and debts. Chances are, even after the sub-prime crisis, a lender will be willing to offer you a bigger mortgage than you think you can afford. Only you can know how much you are willing to set aside for a mortgage payment each month.
No. The purpose of the Keep Your Home California Program is to keep struggling homeowners in their home and prevent avoidable foreclosures. This program is not available for second homes or investment properties, which includes using the home as a rental property. If you lease or rent your home after you receive Keep Your Home California assistance you will be ineligible to receive further assistance and may be responsible to repay the benefit proceeds if you sell your home in the future. If during the active benefit period of any Keep Your Home California program it is determined that your home is vacant, non-owner occupied, and/or rented, Keep Your Home California reserves the right to terminate benefit assistance.
Interest – This is what you are paying to borrow the money for your home. It is calculated based on the interest rate, how much principal is outstanding and the time period during which you are paying it back. At the beginning of the loan repayment period, most of your payment actually is going toward interest, with a small portion going against paying down the principal. Over time this will reverse and more of your payment will go toward reducing the loan balance.
When you're shopping around, don't just check the big national mortgage lenders. Some regional or local banks may offer unique lending programs, especially for first-time homebuyers. For example, the young couple who bought a house from me a few years ago used a 100% financing program from Regions Financial that required no mortgage insurance for first-time buyers with outstanding credit.
A third option – usually reserved for affluent home buyers or those with irregular incomes – is an interest-only mortgage. As the name implies, this type of loan gives you the option to pay only interest for the first few years, and it’s attractive to first-time homeowners because of the low payments during their lower earning years. It may also be the right choice if you expect to own the home for a relatively short time and intend to sell before the bigger monthly payments begin.
Following the financial crash of 2008 and the subsequent collapse of the housing bubble, many (but not all) real estate markets eventually recovered. Entered into in a prudent way, home ownership remains something you should consider in your long-term financial planning. Understanding how mortgages and their interest rates work is the best way to ensure that you're building that asset in the most financially beneficial way.
Mortgages will require mortgage insurance if you have less than a 20% down payment. PMI is between 0.35% – 1.0% annually depending on the type of mortgage program you choose. FHA loans PMI is 0.85% of the loan amount, and is required for the life of the loan. Conventional mortgage PMI is 0.51% and is required until the loan balances reaches 78% LTV.
It’s not uncommon for lenders to pull your credit report a second time to see if anything has changed before your loan closes. Be careful not to do anything that would bring down your credit score while your loan is being processed. So, pay all of your bills on time, don’t apply for any new credit cards, and don’t take out any new car loans until your home loan has closed.
The United Way's 2-1-1 hotline connects people with local assistance programs. By dialing 2-1-1, you can receive referrals to organizations that help with food, housing, employment, health care, prescriptions and more. If you are a struggling homeowner, the United Way can help you find a foreclosure prevention counselor and refer you to available mortgage assistance programs. Trained specialists take calls day or night. The United Way may also provide emergency financial assistance to households in danger of losing their homes. Programs vary among locations.
That depends of you and your goals for this purchase. Is this the house you plan to stay in forever? Is it a starter home you plan on selling to trade up in five years? How long you think you’ll stay in a home will help you decide between fixed- and adjustable-rate mortgages. It will also help you decide whether to focus on interest rate or points.
HARP, or the Home Affordable Refinance Program, is the latest federal program designed to help struggling homeowners with their mortgages. Designed to help people who are "underwater" with their mortgages due to lowered home values, it allows people who owe more on their home than it's worth to refinance their mortgages and get lower interest rates. In this sense it is a sort of emergency mortgage assistance program, but it only works for people who don't have any late or delinquent payments. If you are rejected while trying to refinance your home or go through a loan modification program, HARP may benefit. This only applies if your mortgage is owned by Fannie Mae or Freddie Mac, and you need to owe 125% or less of your home's value in order to qualify.
Insurance: This will be paid to a homeowner’s insurance company of your choice; this is required when you have a mortgage. Lenders require that your insurance cover the cost of rebuilding the home if it is ruined by fire or other disaster. This “replacement cost” is determined by your insurer, and must be agreed to by your lender. Insurance will typically cost $700 to $1,200 per year for a single family home.
Amortization. Each mortgage payment is split so that part goes to paying the principal and the rest goes to interest. In the early years of your mortgage, interest makes up a greater part of your overall payment, but as time goes on, the principal becomes a larger portion because you have a smaller amount of principal to charge interest against. Your lender will provide an amortization schedule (a table showing the breakdown of each payment).
A warm, friendly, and most importantly unbiased place to learn about mortgages, ideally before you make contact with a real estate agent or lender. The more you know, the better you’ll feel, and hopefully all that hard work will help you snag a lower mortgage rate too! So what are you waiting for? Let's go! View all mortgage help topics to get started or check out the latest mortgage tips and news below.
Modify your mortgage loan. In many cases your payment is no longer affordable due to changing personal or financial circumstances. A loan modification can reduce your payments, waive fees, lower your interest rates, and more. Banks and lenders are also offering loan modifications with interest rates as low as 2%. They have determined this is in their best financial interest as well. Learn more on low interest rate loan modifications. Find all of the pros and cons as well as details on modifying mortgages.
According to John Lyons, a broker and real estate agent in Chicago, getting a typical mortgage takes an average of 30 to 60 days. So if you’re itching to buy right away, you’ll want to start the pre-approval process soon so you’re ready to go when you find the right house. Lyons recommends getting pre-approved by a reputable company and having all of your financial documentation ready in order to increase your chances of securing a mortgage in a timely fashion.
Learn about a federal government program, Hope for Homeowners, that is offered through the Federal Housing Authority (FHA). It will help hundreds of thousands of lower income homeowners pay or refinance their mortgages (including subprime). Some forms of help may even be available if the value of your home has significantly declined and if your loan is “underwater”. Continue with Hope for Homeowners.
Note that the Hope for Homeowners program indicated above has been expanded. Families can now receive aid on a second mortgage, and more lenders are participating and cooperating with the FHA. Banks and lenders have been provided further incentive to participate in the program. Find how the FHA Expanded Hope for Homeowners to assist more borrowers.


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PETALING JAYA: The Road Transport Department (RTD) must have Parliament amend the law before it thinks about hauling traffic offenders to court.
Lawyers say nowhere in the Road Transport Act does it say the RTD has the right to drag offenders to court for traffic crimes when they can be fined.
They say if RTD wants to prosecute offenders for a traffic offence, the law has first to be amended to redefine which offences can be compounded and which cannot.
RTD director-general Nadzri Siron was reported to have told New Straits Times that the RTD would be hauling traffic offenders straight to court under its Chinese New Year operations if they committed seven particular road offences.
The offences are overtaking along double lines; driving in the emergency lanes; driving while talking on the phone; running red lights; not fastening the seat belts; jumping queues; and not wearing helmets.
“No compound (fine) will be issued,” he was quoted as saying. Read more


text:
Emilia-Romagna, Italy Genealogy
(Add introductory text and/or image here)
Getting started with Emilia-Romagna research
The region of Emilia-Romagna is divided into nine provinces (similar to counties in the United States):
The State Archive (Ufficio dello Stato Civile) of each province is located in the provincial capital. Municipalities provided the state archives with copies of their original civil registration during the years 1809-1865.
Learn more about Emilia-Romagna jurisdictions.
If you are looking for information on Emilia Romagna, did you will want to read the book "Historical archives in Emilia Romagna," General Guide of municipal historical archives. This report was written by the Archival Superintendency for Emilia Romanga with the help of the Institute for the artistic and cultural nature of the Emilia Romanga.
This volume of over 650 pages and is available for free download from the site
(Your text or images here, or use the table below:)
In order to make this wiki a better research tool, we need your help! Many tasks need to be done. You can help by:

domain: geography


text:
Lent day 15?
Sometimes I forget that this is our life. That we’ve lived through what we have in the next year. Sometimes it feels overwhelming. Sometimes I forget. And then other times I watch copious amounts of medical dramas and I bawl—because as much as I’ve struggled and despaired, I see vividly how heavy it is and has been for medical professionals. Not that I didn’t know. But it’s different seeing it (not sure how to explain it). ((It also makes me want to apologize to a lot of people, a lot of people who deserve it but also don’t)).

domain: sociology


Nick asked him to play the famous heart rate game, (the same one Harry Styles played that showed he had more feelings for an ugly purple sneaker than rumoured girlfriend Camille Rowe)...
After a few personal questions, Selena's face appeared on the screen.
"Hello Nicholas, it's Selena Gomez," she began. "I don't need to say my full name with you, but it is. So I know what you're doing, and I would like to remind you of a time where we all went to Central Park together. It was definitely over 10 years ago. I was wondering if that brought up anything for you. You know, Central Park was really beautiful. It was actually my first time. Maybe that says something? If not, I failed."
That's when Nick's heart rate went up.
"This was at a time where my brothers and I were a boy band, and we were in Central Park," Nick began in response. "And we were very private about our relationship, and she was unhappy that her Central Park experience was ruined by the fact that I walked about 20 feet away from her, even though they were taking pictures of us and obviously we were there together, I was like, 'It'd be better if we stood about 25 feet apart.' So it ruined her Central Park experience. So her and Taylor Swift — who was dating my brother Joe, but we never confirmed it — walked 25 feet behind us as we walked through the park by ourselves."
Watch the hilarious clip below:


Trick Daddy’s Horrifying Mugshot is Because of His Lupus, Rapper Slams Social Media for Making Fun of Him
After spending the weekend as the butt of many jokes on social media and the face of countless memes, the rapper took to his verified Facebook page to share a post he wrote on his personal page the day of his arrest calling out internet bullies for making fun of his illness.
WATCH: Young Joc Spotted Driving for Uber-Like Rideshare App in Atlanta, Fan Tells Him “You Must’ve Fell Off”
Is Yung Joc broke? That's a question fans are asking after the rapper was recently spotted driving for a rideshare service similar to Uber and Lyft.
Trick Daddy just put the "madness" in "mugshot madness" with his latest arrest and mugshot after the rapper was busted for cocaine possession and driving under the influence.
If rap somehow never worked out for Drake and Future, they would probably be great coworkers. Possibly, the littiest blue collar workers ever.
DaBaby was arrested in Miami Thursday and remains in jail Friday (Jan. 3) after police detained and questioned him regarding a robbery that was caught on video.
Mugshot Madness: Young Buck Arrested in Nashville on Felony Warrant, Held Without Bond Until May 2020
Young Buck spent his Christmas in jail after the rapper was arrested in Nashville, Tennessee.
Lil Wayne is reportedly aboard a private jet that was stopped by federal agents at the Miami-Opa Locka Executive Airport in Florida and was searched for drugs and guns.
While the hip-hop community continues to mourn the unexpected death of one of its rising stars, Juice Wrld, Boosie Badazz says he knows exactly who should be blamed for the rapper's tragic demise.
Andre 3000 Says He’s Not Motivated to Make New Music: “My Focus Isn’t There, My Confidence Isn’t There”
For years, Andre 3000 fans have been anxiously waiting for new music, whether it be a solo album or an Outkast project, but a new interview the rap legend recently did with the Broken Record podcast suggests he won't be releasing anything in the foreseeable future.
Tekashi 6ix9ine will NOT be walking away from court today a free man as suggested by previous reports ... because the judge says 13...
“The Breakfast Club” Explains Why Tekashi 6ix9ine Isn’t Welcome Back on Their Show If He’s Released From Prison
With Tekashi 69's potential release looming, the rapper's team has apparently reached out to "The Breakfast Club" hosts Charlamagne Tha God and DJ Envy separately to offer them first dibs on his first interview, however, neither one of them are remotely interested in giving him a platform.
Video Resurfaces of Charlamagne Saying He’ll Suck Tekashi 6ix9ine’s D*ck if He Beats His Racketeering Case
A video clip that has clearly NOT aged well has resurfaced showing "Breakfast Club" host Charlamagne Tha God saying he'll give Tekashi 6ix9ine the gift of oral sex if he ends up beating his RICO case and doesn't spend the majority of his life behind bars.
If you ever find yourself in the presence of the greatness that is Beyoncé, make sure her husband Jay-Z doesn't catch you pulling out your phone and trying to record the moment.
Tekashi 6ix9ine to Be Released From Prison After U.S. Federal Government & DA Drop ALL Charges (Report)
Tekashi 6ix9ine will officially be a free man within the next 72 hours if online reports are to be believed.
New photos of Drake's son Adonis have surfaced on the internet.
Lira Galore Sues Quality Control CEO Pierre “P” Thomas for $15 Million, Says He Beat Her While She Was Pregnant With His Child
TMZ is reporting that Lira Galore filed a $15 million civil suit against QC CEO Pierre "P" Thomas, accusing him of beating her "violently and regularly" while she was pregnant with his child.


text:
QC Terme Bagni Nuovi
We are happy to see you again
We are ready to welcome you in accordance with current regulations.
As always, we would like to offer you a relaxing and carefree stay, guaranteeing complete peace of mind, thanks to our detailed safety protocol created by infectious disease specialist, Dr Paolo Gulisano.
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Grand Hotel Bagni Nuovi
Immersed in the Stelvio National Park, offering cozy rooms decorated in Art Nouveau style, the spa Bagni Nuovi can be reached in bathrobe. Pamper yourself with a customized massage at our Alpine Spa.
Be inspired and inspire others. Share your wellness moments on Instagram, use the hashtag #qcterme and you'll see them appear on our Social Wall.

domain: travel


The GOTRAX G2 e-Scooter is the perfect vehicle to get around town. With a range of up to 11 km and a top speed of 24 kph, you're never too far away from your destination. The GOTRAX G2 features a 200w motor power and solid tires for a smooth ride on any terrain.
Reviews of the GOTRAX G2
Is it the Best Electric Scooter for Kids?
Ultimately, if you are looking for a budget-friendly scooter for children, then the GoTrax G2 is a solid option. It is lightweight, easy to transport, and affordable. Furthermore, the deck is slip-resistant, increasing rider safety. Even though there is no taillight, the LED headlight is pretty strong. You might want to use a stronger one when ridi...
Is the GoTrax G2 the best electric scooter in the world? No. Is the GoTrax G2 the best electric scooter in the world under $250? Probably yes. The small weight and volume, the tires that are immune to flats and don’t require maintenance, the decent performance, the quick charging time, the solid water resistance, and the weight limit able to suppor...


text:
Intervest Offices NV engages in property investment fund business. It operates through the Offices and Semi-industrial Buildings segments. The Offices...
OverviewInvests in 110–270 in dividend-producing equity securities of foreign companiesTarget portfolio allocation: 50% European equity, 40% Asia Pacific equity, 10%...
PT Argo Pantes Tbk
Wisma Argo Manunggal, 2nd Floor Jalan Jenderal Gatot Subroto No.
Jakarta , JK 12930
SIC Code: 2284


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domain: entertainment


text:
Author: Anne Marie Ruff
Publisher: Open Door Press
Publish Date: June 20, 2011
Source: I received a copy from the PR; however, this did not affect my review.
Why You're Reading This Book:
- You're a fiction fan
- You're an armchair traveler
From Amazon.com: "In the coffee-growing highlands of Ethiopia, an Italian scientist on a plant collecting expedition discovers a local medicine man dispensing an apparent cure for AIDS. As the medicine man’s teenage daughter reveals the plants behind the cure, their lives become irrevocably intertwined. Through These Veins weaves together the dramatically different worlds of traditional healing, U.S. government funded AIDS research, and the pharmaceutical industry in an intensely personal, fast-paced tale of scientific intrigue and love, with both devastating and hopeful effect.
All profits from the sale of this book will be distributed to the Campaign for Access to Essential Medicines of Médecins Sans Frontières/Doctors Without Borders and the Institute of Biodiversity Conservation in Ethiopia."
My Two Cents:
"Through These Veins" asks the question about whether the medicine we rely on for some of the most harmful diseases in the world are the result of a scientific miracle or a sneaky business decision made by some suit on the basis of charts and a chance for profit. It's a very real question. I think we all want to believe that pharmaceutical companies have their heads in the right places when it comes to what medicines they come out with but those companies are just that, companies. While it would be nice if they were truly altruistic, they still need to make a profit so it's conceivable that if a drug would not turn a tidy profit, they may choose not to manufacture it or wait until the business aspect is better looking before they put it out. This book explores this topic, which was totally fascinating to me. I do wish that the book had touched on this dilemma a little bit more.
This is definitely a good book for those who like a lot of different settings. You get to see Ethiopia and Washington, DC for starters. My fellow armchair travelers will definitely enjoy this aspect. I don't get a chance to read about any African countries all that much so it was nice to read about a place like Ethiopia that was so new and different to me.
I really liked the characters in this book for the most part but Zahara was definitely my favorite. Zahara is the daughter of a medicine man in a remote village in the middle of Ethiopia's coffee highlands. She is incredibly smart and strong. Those characteristics are definitely on display as the book goes on. She goes through a lot throughout the book but she get through all of that showing so much courage.
Bottom line: A good read about miracle medicine.


text:
Well is none other than................. my daughter Amy!
This is the design she came up with for her Christmas presents Thank you cards. All I did to help was tie the tiny bows & cut out the image using a Nestabilitie die, the rest was up to her.
Stamps: Happy Moments
Card: Lovely Lilac, Pink Passion, Whisper White
Misc: Word Window punch, Marker pens, Nestabilitie die, small flower jewel from own stash
I think I may have found my apprentice.....How old do you have to be to sign up as a SU demonstrator?