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Acute coronary syndrome with ST segment elevation in a patient with Addison disease: Case report and brief review of physiopathological mechanisms: A case study
Affiliations: Department of Physiology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania, Department of Internal Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
- Published online on: June 10, 2020 https://doi.org/10.3892/etm.2020.8855
- Pages: 1230-1236
Copyright: © Maranduca et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
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The primary insufficiency of adrenal cortex was first described by Thomas Addison, in 1855. This had been a fatal condition until 1949, when Kendall, Sarett, and Reichstein introduced the substitution therapy with synthetic glucocorticoids. The most common cause of primary adrenal insufficiency is autoimmune adrenalitis (1). Other causes are represented by adrenoleukodystrophy (2), bilateral hemorrhagic adrenal infarction (3,4), infectious adrenalitis (5,6), and adrenal insufficiency induced by administration of synthetic cortisol (7).
Prevalence of Addison disease in the general population in Europe is of 93-144 cases per million and it is estimated that its incidence will reach 4.4-6 new cases per million per year (8). From a physiopathological perspective, Addison disease is characterized by a deficit of glucocorticoid and mineralocorticoid hormones, with an increase in blood plasma ACTH. Mineralocorticoids are known as hormones of sodium and potassium homeostasis. Aldosterone, the most active mineralocorticoid, acts mostly upon the distal and collecting tubules of the kidney, to stimulate sodium and water reabsorption, altogether with potassium excretion (Fig. 1). The general effect of aldosterone is the increase of volemia and arterial blood pressure. Therefore, the deficit of mineralocorticoids leads to: Hyponatremia and hyperkalemia, severe dehydration, blood plasma hypertonia, acidosis, decreased circulating blood volume, arterial hypotension, and even cardiovascular failure. On the other hand, the most important effects of glucocorticoids include: Hyperglycemia through the stimulation of gluconeogenesis, increased arterial blood pressure, anti-inflammatory and immunosuppressive activity. Overall, the deficit of glucocorticoids causes arterial hypotension, severe sensitivity to insulin and disorders in the metabolism of carbohydrates, proteins and lipids.
A schematic indicating the cardiovascular effects of aldosterone. HTA, arterial hypertension; AVC, stroke.
The association between Addison disease and acute coronary syndrome is rare. The physiopathological mechanisms that cause the acute coronary syndrome with ST segment elevation in Addison disease are partially known. The acute coronary syndrome occurring in response to severe endothelial injury is a major stress form, which stimulates the hypothalamus-hypophysis-adrenal axis, which thereafter modulates the complex neurovascular and hormonal response. The functional hypoadrenalism is accompanied by significant morbidity-mortality in the critical patient (9).
A 71-year-old woman has been brought to the hospital as an emergency case (by ambulance), for dehydration syndrome and lipothymic condition. The patient has hereditary/collateral history in the cardiovascular sphere: Father with stroke and a sister with myocardial infarction. She had been diagnosed with Addison disease 30 years ago (i.e., at her age of 41). She is under treatment with prednisone 5 mg/day. Her last endocrinological examination took place 10 years ago (i.e., at her age of 61). She was hysterectomized for cervical neoplasm 2 years ago (i.e. at her age of 69).
The objective examination upon admission shows: Altered general condition, without fever, normal weight (BMI 22.2 kg/m²), pale dehydrated teguments and mucosa, post-hysterectomy median scar, arterial blood pressure 60/40 mmHg, heart rate 95/min, rhythmic cardiac sounds, aortic systolic murmur III/VI with irradiation on both carotids, lower limbs varices, enlarged abdomen through adipose panicle, mobile with breath, diffusely painful at deep palpation in the inferior abdominal level, palpable liver at the right costal margin, vesical catheter à demeure (normochromic urine).
Biological explorations upon admission show: Severe hyponatremia (124 mmol/l) with hypochloremia (92 mmol/l); acidosis (alkaline reserve 17 mmol/l); nitrogen retention syndrome (urea 93 mg/dl; creatinine 2.34 mg/dl); hyperglycemia (148 mg/dl); leukocytosis (10,460/mm³) with lymphopenia (15.7%) and monocytosis (13%); thrombocytosis (616,000/mm³); hypocholesterolemia (total cholesterol 56 mg/dl; LDL-cholesterol 20 mg/dl, HDL-cholesterol 28.4 mg/dl); hypotriglyceridemia (48 mg/dl); significant glycosuria at the urinalysis. BNP (natriuretic type B peptide) was normal upon admission. Electrocardiogram was also normal at the time of admission (Fig. 2).
Electrocardiogram (ECG) upon hospital admission. Heart rate (HR) 91/min; normal intermediary electrical axis of the heart; SR aspect of the QRS complex. The usual denominations are used for the following: ECG waves (Q, R, S, and T; a non-capital letter refers to a small amplitude of the respective wave); standard bipolar ECG leads (I, II, and III); amplified unipolar ECG leads of the limbs (aVR, aVL, and aVF); thoracic (precordial) unipolar ECG leads (V1 to V6).
Along the first 24 h from arrival to the Emergency Admission Unit, the patient was the subject of the following events, step by step: i) positive inotropic support and hydro-electrolytic and acid-base rebalancing; ii) admission to Endocrinology Clinic; iii) anginous pain and electrocardiographic aspect of extended acute inferior and anterior myocardial infarction (Fig. 3A and B), thus transfer to the Coronary Intensive Therapy Unit (Fig. 4), at the moment of transfer the myocytolysis enzymes being within normal limits and iv) confirmation of infarction diagnosis and immediate thrombolytic therapy, which proved to be successful. During monitorization in the Coronary Intensive Therapy Unit, after for ten days, another acute Addison episode occurred and the patient was again subjected to rebalancing, but this time the endocrinologist opinion was asked for and the decision was taken to increase the prednisone dose to 7.5 mg/day (5 mg each morning and 2.5 mg each afternoon).
Electrocardiogram (ECG) during angina. Traces correspond to the standard leads and (A) unipolar leads of the limbs and (B) to the thoracic (precordial) leads. Analysis: Heart rate (HR) 116/min; normal intermediary electrical axis of the heart; qR aspect of the QRS complex and ST segment elevation in leads I, aVL, V5, and V6; QRS complex appears as a large monophasic wave in leads V2, V3, and V4. The usual denominations are used for the following: ECG waves (Q, R, S, and T; non-capital letters refer to a small amplitude of the respective wave); standard bipolar ECG leads (I, II, and III); amplified unipolar ECG leads of the limbs (aVR, aVL, and aVF); thoracic (precordial) unipolar ECG leads (V1 to V6).
Electrocardiogram in the Cardiologic Clinic. Heart rate (HR) 99/min; normal intermediary electrical axis of the heart; arterial blood pressure (BP) 75 mmHg. The QRS complex has the following aspects: qR in leads I, II, aVL, V5, and V6; QS in leads III, aVF, and V1; QrS in leads V1, V2, and V3. ST segment elevation of ascending type is present in preordial leads V2 to V5. The usual denominations are used for the following: ECG waves (Q, R, S, and T; non-capital letters refer to a small amplitude of the respective wave); standard bipolar ECG leads (DI, DII, and DIII); amplified unipolar ECG leads of the limbs (aVR, aVL, and aVF); thoracic (precordial) unipolar ECG leads (V1 to V6).
The positive diagnosis of acute myocardial infarction was based on the clinical and electrocardiographic criteria. Thrombolysis was applied, using Metalyse 10,000 U, with clear subsequent favorable evolution (Figs. 5,6), without an increase of the myocardial cytolysis enzymes. In fact, myocardial enzymes, including troponin, were normal both before and after thrombolysis. Echocardiography performed during chest pain showed hypokinesis of the left ventricular apex and hypokinesis of the lower wall, with an ejection fraction in normal limits (50%). Emergency coronary angiography could not be performed, because the service was unavailable at that time.
Electrocardiogram (ECG) immediately after Metalyse 10,000 u. Heart rate (HR) 90/min; normal intermediary electrical axis of the heart; arterial blood pressure (BP) 85 mmHg. The QRS complex has the following aspects: qR in leads I, II, aVL, V5, and V6; QS in leads III, aVF, and V1; QrS in leads V2, V3, and V4. ST segment elevation of ascending type is present in precordial leads V2 to V5. The usual denominations are used for the following: ECG waves (Q, R, S, and T, where non-capital letters refer to a small amplitude of the respective wave); standard bipolar ECG leads (I, II, and III); amplified unipolar ECG leads of the limbs (aVR, aVL, and aVF); thoracic (precordial) unipolar ECG leads (V1 to V6).
Electrocardiogram one hour after Metalyse 10,000 u. Heart rate (HR) 90/min; normal intermediary electrical axis of the heart; arterial blood pressure (BP) 85 mmHg. The QRS complex has the following aspects: qR in leads I and aVL, V5, and V6; Qr in leads II and aVF, QS in lead V1; qrS in leads V2, V3, and V4. ST segment elevation of ascending type is present in precordial leads V2 to V5. The usual denominations are used for the following: ECG waves (Q, R, S, and T, where non-capital letters refer to a small amplitude of the respective wave); standard bipolar ECG leads (I, II, and III); amplified unipolar ECG leads of the limbs (aVR, aVL, and aVF); thoracic (precordial) unipolar ECG leads (V1 to V6).
The clinical examination did not reveal cushingoid manifestations (as possible adverse effect of an uncontrolled glucocorticoid replacement therapy), while hormone measurements showed the level of cortisol was 10.6 µg/dl and that of ACTH was 398 pg/ml. The abdominal CT performed shows, on the topography of the adrenal glands, two inhomogeneous iodophile formations, with calcareous structure.
So, prednisone was increased, from the previous dose of 5 mg/day to the current dose of 7.5 mg/day, with the indication to increase the dose up to 10-15 mg/day in case this was required by intercurrent stress events. The lower prednisone dose, of 5 mg/day, proved to be insufficient in situations of superimposed acute events, allowing manifest Addison crisis to occur. With this higher prednisone dose, the patient has been stable thereafter, without any acute cardiovascular or endocrinological manifestations.
Cardiovascular diseases constitute an important public health issue in industrialized countries, in terms of both morbidity and mortality. The most important mortality cause in the entire world is atherosclerosis. The most feared complication of chronic inflammation of the vascular wall, with the highest mortality rate, is the acute coronary syndrome with ST segment elevation (10). Atherosclerosis produces rigidity, narrowing and obstruction of coronary arteries. Inflammation represents the key element in the initiation, progression and destabilization of the atheromatous plaque (10). Endothelial dysfunction is currently considered the trigger factor in the pathogenesis of atherosclerotic plaque. Pro-inflammatory cytokines, such as TNF-alpha (tumor necrosis factor) (11) and IL-1 beta (interleukin 1) (12) act on endothelial cells to initiate a cascade of events that ultimately affect the endothelium anti-adhesive and anticoagulant properties and also its permeability. Alteration of endothelial permeability allows LDL accumulation in the heart and favors the adhesion of circulating monocytes/macrophages (13) and the formation of thrombi through the increase of the pro-aggregant and pro-coagulant functions. Unfortunately, no cytokines were measured in the particular clinical case under discussion here.
Cortisol and ACTH are involved in atherogenesis, by modulation of the endothelial functions, by recruitment of circulating monocytes and their differentiation into macrophages, and by production of pro- and anti-inflammatory interleukins. Furthermore, these hormones are involved in development of acute coronary syndrome, by modulating platelet aggregation and thrombogenesis (14). Coronary atherosclerosis has a multi-factorial etiology, which includes non-modifiable factors (age, male sex, family predisposition) and modifiable factors (dyslipidemia, arterial hypertension, smoking, diabetes mellitus, obesity, sedentary lifestyle). Coronary atherosclerosis is a silent process which evolves in stages of years or tens of years.
In the case of our patient, coronary atherosclerosis is the main cause for the acute myocardial infarction that she developed during hospitalization. As reasons for these circumstances we have the patient's age, the hereditary cardiovascular history, the presence of systolic murmur at the level of carotid arteries, as well as the fact that she is at menopause. It is known that the clinical manifestations of atherosclerosis occur after the fifth decade of life in women, when the anti-aterosclerotic protective effect of oestrogen gradually decreases at the onset of menopause.
Addison disease, also called primary corticoadrenal insufficiency, is a hypofunction of the adrenal gland. From a physiopathological perspective, the Addison disease appears as an insufficient secretion of glucocorticoid and mineralocorticoid hormones. The deficit of glucocorticoid hormones leads to arterial hypotension, dysfunctions in the metabolism of carbohydrates, lipids and proteins and the decrease of insulin sensitivity. The deficit of mineralocorticoid hormones leads to an increase of the sodium excretion and a decrease of the potassium excretion in urine, which leads to hyponatremia and hyperkalemia. In this context severe dehydration appears, accompanied by decreased circulating volume and arterial hypotension.
Clearly applicable to the case presented here, a more detailed analysis of the involved pathophysiological mechanisms reveals the following. Hyponatremia, severe dehydration and hypovolemia are accompanied by decreased blood pressure and consequently, decreased myocardial perfusion occurs. On a pre-existing atherosclerotic background, prolonged low blood pressure may contribute to myocardial infarction, with an oxygen supply-demand disproportion appearing in the myocardium. In Addison disease, low blood pressure occurs, on one hand by decreased cortisol synthesis, and on the other by severe hyponatremia, which leads to decreased water reabsorption and extreme dehydration, with decreased circulating blood volume. These factors may participate in destabilizing the atheroma plaque and in the onset of acute coronary syndrome with ST elevation. Such a mechanism is advocated for by the following aspects present at the time of hospitalization: Dehydrated teguments and mucous membranes at the clinical examination; arterial blood pressure 60/40 mmHg, severe hyponatremia (124 mmol/l).
The depletion of endogenous glucocorticoids is correlated with the development of the myocardial dysfunction. In murine models, adrenalectomy was associated with an impairment of the myocardial contractility through the depletion of the microsomal phosphorylase activity and a significant reduction of calcium absorption in the sarcoplasmic reticulum. These lead to a glycogenolysis dysfunction and the depression of the myocardial contractility. Moreover, the glucocorticoids deficit reduces the expression of adrenergic receptors and adrenalin synthesis and affects the cardiovascular reactivity to catecholamines. These mechanisms could explain the severe myocardial dysfunction associated to adrenal insufficiency (15). However, we could not identify animal studies explaining mechanisms associated with the occurrence of acute coronary syndrome in adrenal insufficiency.
Treatment of Addison disease includes glucocorticoids. Glucocorticoids stimulate atherogenesis and vascular remodeling (16), via glucocorticoid and mineralocorticoid receptors, a phenomenon which involves the local enzyme 11b hydroxysteroid dehydrogenase (17). In case of prolonged cortisol treatment, the vasoconstriction that sets in is a consequence of the decrease of nitric oxide production at the vascular level (18). At the same time, the administration of glucocorticoids produces an imbalance between the vasoconstrictor and vasodilating factors, through decreased synthesis of vasodilating prostacyclin and the increase of the vasoconstricting thromboxane (19). Our patient was diagnosed with Addison disease 41 years ago, thus she received substitution treatment with prednisone starting at that time. Prolonged administration of glucocorticoids increases the risk of cardio-vascular events (20), but in patients with Addison disease the adequate corticosteroid treatment is required as substitute and the risk of cardio-vascular events is minimal. Moreover, this patient had hypoadrenalism and only took a very small dose of glucocorticoid replacement therapy, so the mechanisms described in this paragraph actually do not apply. On the other side, only an overdose of glucocorticoids promotes pro-atherosclerotic dyslipidemia, as trigger for acute coronary syndrome, which is also not the case here.
Maybe above all, this case presentation shows an interesting acute issue, as follows. In the atherosclerotic context and with a relatively sufficient chronic corticoid substitution, a manifest acute Addison episode may lead to myocardial infarction. In our case the infarction was mainly of thrombotic cause, as shown by the successful thrombolysis. The hypotensive crisis lead to emergency hospitalization and the patient suffered the infarction the same day after admission and rebalancing. Even more, she had another Addison crisis ten days later, which imposed an increase in the corticoid substitution dose. The pathogenic complex behind this sequence of events involves all the aspects discussed above, regarding the atheroma in such conditions. Maybe with a special relevance of all the abrupt hemodynamic changes, reflected in major and sharp changes in shear stress, under circumstances of blunted flow-mediated dilation due to endothelial dysfunction.
To conclude, in case of a patient with Addison disease, the pre-existing coronary atherosclerosis is the main cause that leads to the development of acute coronary syndrome with elevation of ST segment. The severe hyponatremia, dehydration, and hypovolemia, all found in this adrenal cortical insufficiency, can be considered trigger factors, but they could not cause acute coronary syndrome without the pathological basis of atherosclerosis. Such factors, on a pre-existing atherosclerotic background, increase the risk of major cardiovascular events, such as acute myocardial infarction with ST-segment elevation, as in our case report. This multifactorial pathogenic scene needs to include thrombosis, coronary spasm and low blood pressure as causes of myocardial infarction. These three mechanisms are more or less related to the context of Addison disease and the required corticotherapy, as discussed above. Last but not least, the conclusion of this article is that corticoid substitution therapy, which may seem sufficient, can become insufficient along the evolution of cardiovascular disease (mainly with age), thus leading to the manifest Addison crisis and even to major ischemic events, as in the case discussed here.
No funding was received.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
MAM, CS, DNS and ILS contributed to conception and design of the current study. MAM, CS, RAS, ND and LLH acquired the data. All authors analyzed and interpreted the data. MAM and CS drafted the manuscript and RAS, ND, LLH, DNS and ILS revised it critically for important intellectual content. All authors gave final approval of the this version of the manuscript to be published.
Ethics approval and consent to participate
Informed consent was obtained from the patient.
Patient consent for publication
Informed consent has been obtained from the patient regarding the publication of the case details and any associated images.
The authors declare that they have no competing interests.
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The Mississippi Department of Mental Health filed temporary Mississippi Youth Programs Around the Clock (MYPAC) standards on October 14, 2021. Due to the nature of a temporary filing, no public comment period is required prior to the temporary rules becoming effective. The Department will soon be submitting to the MS Secretary of State’s office a typical (i.e., permanent) filing of the proposed new MYPAC standards to become incorporated into the current (2020) Department’s Operational Standards document. Once these proposed permanent MYPAC standards are filed with the Secretary of State, there will be an approximate 25-day public comment period. Then, there will be a filing of the rules for final adoption, and there will be a 30-day period after this filing before the permanent rules are adopted.
This is the provider bulletin with policy changes about (MYPAC) and these are the MYPAC temporary standards to accompany the bulletin. The standards explain how the proposed policy will be implemented. We encourage families and others to review the provider bulletin and standards so that you can share your feedback when the comment period is opened.
There have been several changes made to MYPAC over the past few months, and at one point the program was stopped altogether. The issue that originally led to these changes is the need to separate wraparound, the care coordination process that is used by programs offering MYPAC, from the MYPAC services that children and families receive. If wraparound coordinators work for the same agencies that offer MYPAC services, they may feel obligated to offer services to families just from their own agencies. This prevents families from having all of the choices that they should have and it may make it hard for families to tell their care coordinators when they don’t like services or want to switch to a different provider.
It is important to understand the difference between wraparound and MYPAC in order to evaluate this policy, the standards that accompany it, and other changes that have been proposed since June. Wraparound is a care coordination process with nationally recognized standards for how it should be delivered that is driven by ten principles:
- Family Voice and Choice
- Natural Supports
- Unconditional Care
- Culturally Competent
There is growing evidence that Wraparound helps families and children achieve the goals that they want to achieve. The practice of Wraparound is consistent with the nationally accepted definition of family-driven practice in that both emphasize the driving force of family voice and choice, individualized service planning and a strengths-based approach. Wraparound is a key component of the Mississippi state law governing Mississippi’s system of care for children’s mental health as noted in lines 56-72 from the statute (emphasis added):
“The Mississippi Statewide System of Care shall be:
(a) Child-centered, family-focused, family-driven and youth guided;
(b) Community based;
(c) Culturally competent and responsive; and shall provide for:
(i) Service coordination or case management;
(ii) Prevention and early identification and intervention;
(iii) Smooth transitions among agencies and providers, and to the transition-age and adult service systems;
(iv) Human rights protection and advocacy;
(v) Nondiscrimination in access to services;
(vi) A comprehensive array of services composed of treatment and informal supports that are identified as best practices and/or evidence-based practices;
(vii) Individualized service planning that uses a strengths-based, wraparound process; “
There are also national wraparound standards to help agencies and states implement and provide wraparound in the way it was intended. One of these standards is that there should be a firewall between care coordination and services at the agency level and in the way the state sets up wraparound and mental health services. That is why Mississippi has made changes attempting to separate the wraparound process from services. There are different ways to set up firewalls. Sometimes agencies completely separate wraparound and services within one agency with different staff, supervision and locations. In other instances, wraparound is provided through organizations called Care Management Entities (CME) that do nothing but provide wraparound. Initial data indicate that the CMEs have better wraparound implementation than mental health centers that attempt to separate wraparound and services in one facility.
States should also have standards and processes to make sure that agencies have this separation. It does not appear that Mississippi has this process in place and it is not clear what agency will ensure that this happens. We believe the Interagency Coordinating Council on Children and Youth (ICCCY) can help provide guidance and support on this issue and others related to MYPAC and wraparound. The Mississippi Wraparound Institute gathers wraparound data and provides coaching on wraparound, including to MYPAC providers, but there is not a clear process for how this data can be used to make sure challenges with wraparound are accountably addressed and providers receive the ongoing support that they need when challenges are identified. Maximizing this resource and data is likely another area in which the Council can be of support.
MYPAC, in contrast to the process of wraparound care coordination, is a set of services that have changed over time and for which there is no current state, national or independent evidence of their effectiveness, although some of the agencies that offer MYPAC have internal data that indicates the services help children stay in their homes and communities. At a Division of Medicaid public hearing in June 2021, Pine Belt Mental Health Services shared data that children receiving MYPAC services were less likely to require hospitalization and Youth Villages Mississippishared that families reported better functioning of their children who were involved in MYPAC. The children and families from both of these organizations would have also been receiving wraparound care coordination in addition to MYPAC services.
MYPAC began in the mid-2000s. It was designed to provide intensive home and community-based services and supports to children and youth who would otherwise need admission to psychiatric residential treatment facilities. It was based on extensive focus group data from families throughout the state. The original proposal for MYPAC funding included comprehensive parent-to-parent support (including parents being the ones to initially introduce MYPAC to families), a wide array of informal and formal supports both within and outside of the mental health system and wraparound care planning. There was an objective evaluation process for MYPAC services. MYPAC was monitored by the Division of Medicaid and coordinated with councils and teams established in Mississippi law to oversee and facilitate Mississippi’s system of care for children’s mental health.
MYPAC has changed over the years, in part due to changes in the way it is funded. It was originally a Medicaid waiver service and is now a Medicaid state plan service. Families are now typically referred to MYPAC by mental health service providers, often providers from whom their child has received residential care. The service array is not as diverse or individualized as it was originally and usually includes weekly in-home visits for therapy, care coordination and parent peer support, with medication management provided separately. Wraparound coordination is offered but it is almost always offered by the same organization that is providing services. After its first few years of existence, MYPAC outcomes were not monitored by any external entity.
Services for MYPAC have traditionally been billed at a bundled daily rate for the days that they are delivered. So, if just one service is provided on a given day, the provider can bill for a higher rate than if that service were individually charged. Bundled rates can help providers provide flexible care because it cannot always be predicted what services might be most helpful to a family on any given day. Bundled rates can also help cover the cost of responding to complex and involved needs that youth and families may have. At the same time, bundled rates can make it easier for providers to repeatedly bill for the bundled rate when only one one-hour service per day is offered. Families as Allies has obtained some information about MYPAC billing patterns through public information requests to the Division of Medicaid and we have asked the Division for guidance on whether we can share this information more broadly.
MYPAC is not part of the state law that describes how Mississippi’s system of care shall be conducted, but it is important to evaluate any MYPAC proposals against the law to see if those proposals are consistent with family-driven practice and an individualized strengths-based approach and are coordinated using wraparound.
Our initial review of the Department of Mental Health’s MYPAC proposal and accompanying standards indicates features that are not consistent with Mississippi’s system-of-care statute. The policy and standards do not holistically incorporate wraparound, they do not appear to be strengths-based and they offer a restricted range of formal mental health services rather than the range of services and supports that families typically want. The policy does not require the use of evidence-based treatments.
It is concerning that there are no provisions in the policy or standards for how providers will be monitored to ensure that they refer to this intensive, high-end service only when indicated and that their billing patterns reflect that, especially since it appears they will be self-referring to the program. The policy makes it clear that other stakeholders, including families and family-run organizations, were not included in the development of the policy, but that the Department worked only with the Division of Medicaid to create it.
It is also puzzling that the policy refers to MYPAC as an “important service for Mississippi’s children, youth and their families” given MYPAC has changed and without explaining how or by whom the importance of a service is determined. We are not aware of families being part of this determination.
Families as Allies wants to help families understand policies and regulations when they are open for comment. That is why we share information such as this blog post. At the same time, remember that you do not have to agree with what Families as Allies or anyone else says about a policy or service. You also do not need to understand every detail of a policy in order to comment on it. As a parent, you already are an expert on two things that no one else is: your child and what you think would most help your child. What you think matters and can make a big difference in whether policies help our children. The definition of family-driven practice includes this principle: “Families and family-run organizations provide direction for policy decisions that impact funding, supports, and services, including the right of families and youth to have meaningful voice at the individual and policy level.”
We encourage you, especially if your family has participated in MYPAC and/or wraparound, to write down your feedback and ideas about this policy and its accompanying standards. You can comment about what the policy and standards say or share your ideas about how you think MYPAC and wraparound can be most helpful separate and apart from the proposed policy and standards.
These are some related points to keep in mind when thinking about comments about wraparound and MYPAC:
- Wraparound and MYPAC are both intended for children and youth who would otherwise need the level of care of a psychiatric residential treatment facility. If your child was referred to MYPAC or wraparound, were their needs intense enough to otherwise need out-of-home care?
- Both wraparound and MYPAC should be individualized to children and families. If your child and family participated in either or both, were the services and how often and where they were delivered set up in a way that worked for your family?
- Both wraparound and MYPAC should support choice in providers and other supports. If your family participated in either or both, were the providers that you were working with or wanted to work with part of your team? Were people who are important to your family (for example, friends, family, church members) included?
We also encourage everyone to consider if it makes more sense to strengthen high-fidelity wraparound in the state, given the promising evidence for it and the state and national resources already available to support it rather than to implement a new rendition of MYPAC that does not have fiscal accountability measures or an evidence-base.
We will update our website and our Facebook page when the public comment period is open.
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The Infantry Assaultman easily slipped into roles that were not his own and excelled. Why? Nobody really knows, it was just what he did. The Marine Corps is doing away with its infantry assaultman military occupational specialty and phasing out the assault section of Marine. When I realized today was time for Strip #51, I decided to do a tribute to my personal MOS: The Assaultman. It is kind of the odd-ball of the.
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Neller also confirmed that the Marine Corps plans to replace the SMAW in its breaching mission with the Carl Gustaf 84mm recoilless rifle, a possibility first reported exclusively by Military.
Ode to the infantry assaultman
When he deployed to Iraq, he said, he ended up filling the always in-demand role of machine gunner. Guided Missile Destroyer’s Command Master Chief Fired Navy officials said they had identified misconduct during an ongoing investigation.
The service would add 3, Marines in and now expects an additional 1, thanks to the recently signed National Defense Authorization Act. That axsaultman will likely take place in the next four years. Poll Shows Veterans’ Support for Trump Is Strong Male veterans were much more likely to approve of Trump asszultman those who haven’t served, 58 percent to 46 percent.
It makes sense to cut the infantry assaultman MOS in part because it contains Marines of more junior ranks — private to sergeant — and its training overlaps with that of the other infantry MOSs, he said.
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0351 Infantry Assaultman
He could do that. Each future rifle company will have an element of combat engineers aligned with it to take on breaching and demolition duties.
He was a renaissance man of the infantry. My Profile News Home Page. Marine Corps leaders made clear in early that they wanted a significant increase in end strength: He had to be.
Current Edition Subscribe Digital Edition. Most Popular Military News. More from American Grit: Robert Neller, who confirmed planning in December while on an annual tour of deployed Marine elements around the world, said he expects the move to happen in the next three to five years as part of a slate of changes designed to help the Corps prepare for future fights.
Military figures we lost At the close ofit’s time to remember some of the notable service members we lost through the year. The Infantry Assaultman easily slipped into roles that were not his own and excelled. The infantry assaultman, one of the Marine Corps’ five assaultmab infantry positions, is tasked with breaching, demolition, and rocket fire against fortified positions.
DVIDS – Video – Infantry Assaultman
But we had to give up something to get something else. The infantry assaultman was smart. Originally published at American Grit. But more women are joining the military, and they are bucking the pattern. Follow her on Twitter at HopeSeck.
Do you need a whole MOS for that? Nobody knew what to do with the assaultmen, so while they maintained their specific MOS skills, they also learned and picked up the skills from others as well. Trump Slowing Down Troop Pullout from Syria Graham had been an outspoken critic of Trump’s decision, which had drawn bipartisan criticism.
In an interview with Military. His job required that he be able to distinguish between friendly and enemy tanks through a thermal optic, memorize several different equations for demolitions and numerous explosive values, all in the blink of an eye.
Marine Corps to Cut Infantry Assaultman Job to Resource Other Roles |
Because of the specific, niche nature of the job, he said, s end up doing other jobs on deployment. At seven Marines in a company assault section, three companies in a battalion, and 24 battalions in the Marine Corps, the move will leave more than spots available in the service to fill other jobs.
In addition to cyber, Neller said he’s looking to build up intelligence analysis, air defense, and maintenance for ground vehicles and aviation.
The Marine Corps is doing away with its infantry assaultman military occupational specialty and phasing out the assault section of Marine rifle companies in assault,an effort to build up communities such as cyber and electronic warfare, Military.

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AST 1591 - Battle with the Juxtapose Phoenix, Qing Shui’s Departure
Yiye Jiange chuckled. “I don’t mind.”
Yiye Jiange smiled while she said those words but not because she didn’t care about Qing Shui. Rather, she knew that some things were out of her control. Since she had chosen him, she would accept everything about him, including his women.
She had basic knowledge about all the women by Qing Shui’s side. All of them were stunning and were chosen from millions of others. They were all outstanding, but like all these women who were willing to commit to him, wasn’t she the same as well?
Qing Shui could sense Yiye Jiange’s emotions from the side and felt a wave of guilt, but there was nothing he could do except send an apologetic look her way.
Yiye Jiange reciprocated with a smile. “Just be yourself. If either of you forsakes the other after this, then they’d have left the other’s side anyways. Since it’s like this, it just means you’ve been chosen for who you are.”
“To be able to marry you is my reward for eighteen generations of virtue. God has bestowed you to me in this life.” Qing Shui said with delight.
“Alright, I wasn’t serious about it so both of you don’t have to get all mushy on me. Can you consider my feelings too?!” Muyun Qingge spoke up. What she really felt, even she wasn’t sure.
“What are both your plans in the near future?” Qing Shui asked, indicating that he was planning on making his departure soon.
“You’re planning on leaving already?” Muyun Qingge stated softly while Yiye Jiange remained quiet. Qing Shui had once invited her to leave with him but after much consideration, she decided to stay. She still felt that this was the right choice.
“Mm, perhaps in the next three to five days. Will the Sea King’s Palace be expanding in this area? If you’re staying here, it’ll be easier for me to come back. Oh, that reminds me, you can shift the Sea King’s Palace a little to the South—it should be better there than here. Or maybe just build a palace in that area and you can both stay there.” Qing Shui said after some thought. He was referring to where the Jade Kirin Dragon Vessel was.
If the two women stayed there, not only was it full of spiritual Qi, but also it’d also be easier for him to locate Yiye Jiange.
“You’ve found somewhere good?” Yiye Jiange laughed. The two women were both intelligent and could tell that much between the lines of Qing Shui’s response.
“I stumbled into a water tunnel previously, and it turned out to be a former Divine Cave. There’s ample spiritual Qi there; if either of you stay in there for a period of time, I’m sure it’ll be beneficial.”
Qing Shui had planned to go into the spiritual cave on his own. With the long period of vacancy, the accumulated spiritual Qi was exceptionally dense.
“You should go instead. Once your might gets stronger, the Sea King’s Palace will likewise be safe.” Muyun Qingge said with a smile.
“The spiritual Qi there won’t be exhausted by just one or two people. It’s a spiritual cave and the spiritual pulse should be decent. Its location is concealed too; I had set a formation there. I’ll tell you how to go there now. Even if you don’t expand your territory, you can still cultivate there.” Qing Shui said with a shake of his head. The spiritual Qi there really wouldn’t be much use for him. Compared to the Realm of the Violet Jade Immortal, the latter was much better in terms of returns for the time spent. A day spent in the Divine Cave would be equivalent to ten days outside.
The two women didn’t stand on ceremony any further and Qing Shui likewise taught them about the formation before bringing them to their destination.
Once they arrived, Qing Shui smiled at the surrounding mountains. “Building the Sea King’s Palace here won’t be too bad either. The mountain range here is overflowing with immortal Qi.”
“I did think about it. Since it was a Divine who built this, then there must be something special about it.” Muyun Qingge said seriously.
She smiled towards Yiye Jiange when she was done. “What do you think, Jiange?”
“It’s pretty good since the Sea King’s Palace needs to expand its power anyway and it isn’t too far away. Regardless of location or other conditions, it’s a decent spot.” Yiye Jiange scrutinized their surroundings before replying.
“Alright, that’s a deal then. We’ll build a small palace here and conceal this cave within it. Thereafter, we’ll begin expanding out gradually. For now, let’s live here with a few others.”
Talking as they walked, the two women managed to get into the formation without a hitch. Going through the concealed boundary, they let out an uncontrollable moan just like Qing Shui did upon his discovery. They covered their mouths in haste before flashing shy smiles at Qing Shui.
The soft moan that was caused by a surge of refreshing comfort had Qing Shui’s blood pumping. Qing Shui had heard it numerous of times from Yiye Jiange but she was still shy, shooting an annoyed glance at him.
Muyun Qingge swept a glance with her flushed face at Qing Shui but soon enough began measuring up their surroundings.
“This is the cave of the Jade Kirin Dragon Vessel—there’s a statue of him inside. There should be some spiritual sense left behind by him downstairs. Although it isn’t huge, it isn’t tiny in here either; there should be enough space. You won’t even have to clean up this spiritual cave—with such overwhelming influx of spiritual Qi, the atmosphere will be cleansed accordingly.”
There were a few partitions in this place that Qing Shui found during his previous visit. These should be rooms for the people who were staying here to cultivate. Qing Shui had planned to stay here with the women for a few days to teach them a few formations and while he was at it, a new set of combat skills that he just learned as well.
The names of both the Phoenix and Kirin were androgynous, when in actual fact, there was a male and female gender for both creatures. This combat skill was the latest technique of the Phoenix, and it was meant for two people to complete.
It was a combat skill designed for a husband and wife pair, but the technique didn’t make this a requirement. As long as it was used between a pair of people within a certain distance, they would be able to increase their strength by 10%.
However, if they were husband and wife, it would be increased by 20% and even more if they were of one mind—there wasn’t an exact gauge as to how much it could increase by.
“If you could stay with Jiange, then your strength would have increased by a substantial amount—it’s a pity you can’t.” Muyun Qingge said regretfully.
“Actually, it’s pretty tough to master the skill, tougher than you’d expect. Even if you’re husband and wife, you might only see an increase of 20%, which is why there are many who don’t dare to.” Qing Shui smiled.
“Why not? Who knows... they might be able to increase by 50% in their strength if they’re as one.”
“It’d be great if they were of one mind, but there aren’t many instances of those in this world. The standards for being of one mind are high: to share the same ideals, to have a love tougher than gold, with alignment in perspective towards life, as well as strength, sentiments towards each other, hobbies, sense of good and evil, judgement and plans for the future… So, it’ll be better if the both of you learn this instead, even if you don’t increase your strength by too much.”
Qing Shui’s last sentence had incurred the wrath of the two women who wanted nothing more than to give him a beating. If the two of them got to the point where they were of one mind, then Qing Shui might just cry. Of course, the chance of this was near zero and he was merely joking.
It wasn’t difficult to learn, as it was just a technique like any other. The only exception was that they could only use it if they were both in battle together, but at that point, they could unleash it easily.
Qing Shui hadn’t mentioned this, but he had never planned to learn this with his women. Perhaps it was more accurate to say that he never planned to use this at all because the technique would only work best between just one pair of husband and wife.
It wasn’t an absolute waste though and so Qing Shui kept the skill, planning to teach it to friends or relatives who would need it.
Yiye Jiange was deep in thought when she looked towards Qing Shui. She realized they were still connected by their heart and soul, but it was a pity that the man she loved would never be tied down by just one woman. Even an outstanding woman would be attracted to him like a moth to a flame without hesitation, even after knowing he had other women by his side. She was one of them and it wasn’t like she wanted repayment in gratitude—there wasn’t such a thing left between them. As long as either of them was reluctant, then neither would force the other.
There were a lot of formations that Qing Shui knew. On the other hand, the two women didn’t have an exceptional talent for using them. Still, they weren’t terrible at it and could even be considered superior to normal people. During the next few days, Qing Shui taught them quite a number of formations, mainly those that were simpler and could be layered. This way, even if Qing Shui wasn’t with them, they could research after understanding the logic behind them and create their own formations.
With a blink of an eye, several days passed and it was time for Qing Shui to go. Yiye Jiange couldn’t bear to see him leave and ended up sending Qing Shui off for thousands of miles before hugging him tightly, unwilling to let go.
“Why don’t you leave with me?” Qing Shui said with a smile.
“I can’t abandon the Sea King’s Palace. Be good, we’ll have lots of time once the Sea King’s Palace is done with its development.” Yiye Jiange replied softly.
Qing Shui chuckled. This was the first time he had heard her with such a motherly tone, and it sounded exceptionally comforting. With a tight hold around her, he continued, “I’ll find you every time I miss you. It’s really convenient. Reunion after a brief parting is as sweet as a new marriage—are you excited for our next meeting? I’ll leave you walking on Cloud Nine.” Qing Shui left a kiss on her ear.
Yiye Jiange’s breathing became increasingly labored as she held his face in her hands. “Alright, Qing Shui. I can’t endure you doing that. I really hadn’t expected you to have such strong desires.”
Qing Shui smiled at her. “Then do you like that my desires are this strong…”
“You’re terrible. I do... are you satisfied now?” Yiye Jiange held onto that sly hand of his and said softly.
Before he left, he had already been entangled with her for more than half a day, and he was only teasing her now. With a light kiss to her face, he bid his farewell. “Take good care of yourself.”
“I will. You have to take care of yourself too.”
Even though farewells were heartbreaking, both of them were composed. It was only when Qing Shui disappeared from view that Yiye Jiange exhaled the breath she was holding.
“Why didn’t you follow him if you couldn’t bear for him to leave?” Muyun Qingge appeared beside Yiye Jiange.
“A woman and a man should always maintain an appropriate distance. While I can’t let him forget about me, I can’t have him getting tired of my presence as well. I’m afraid he will forget about me, but I’m more scared that he will get sick of me.” Yiye Jiange smiled at Muyun Qingge.
No matter how beautiful a woman is, as soon as the novelty rubbed off and she was without a trace of mystery, then she would likewise not feel as cherished anymore—both in action and thought.
“So our Goddess-like beauty has the same fear that she won’t be fancied too?” Muyun Qingge froze for a moment before breaking out in a giggle.

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Libraries and museums build the civic strength of their communities and providing opportunities for public engagement.
Search the Awarded Grants database for grants to programs that strengthen civic/community engagement (issue areas have only been assigned to grants awarded since FY 2009)
National Initiative: National Medal for Museum and Library Services
The National Medal honors outstanding institutions that make significant and exceptional contributions to their communities. Selected institutions demonstrate extraordinary and innovative approaches to public service, exceeding the expected levels of community outreach.
Each year, select museums and libraries receive the National Medal for Museum and Library Service, the nation’s highest honor for these institutions. Beginning with the 2009 winners, personal stories demonstrating the ongoing impact of these award-winning institutions are being documented through a cooperative agreement between IMLS and StoryCorps.
Civic/community engagement content on the IMLS Web site:
August 29, 2014 12:26 PM
Omeka Development Team Manager Patrick Murray-John Used IMLS’s Museum Universe Data File to create US Museums Explorer
August 18, 2014 02:21 PM
Libraries in Idaho are advancing libraries as community anchor institutions and preparing new generations for college and careers through early literacy efforts and by promoting digital proficiency.
August 15, 2014 02:11 PM
Inaugural National Student Poet, Claire Lee, returns to interview the 2013 Class of National Student Poets. Learn more about National Student Poet Nathan Cummings and the highlights of his year as an ambassador of poetry.
August 11, 2014 10:29 AM
Inaugural National Student Poet, Claire Lee, returns to interview the 2013 Class of National Student Poets. Learn more about National Student Poet Michaela Coplen and the highlights of her year as an ambassador of poetry.
July 31, 2014 10:19 AM
The New Hampshire State Library is aiming to make sure the state’s small libraries can offer the same level service as urban libraries by forming partnerships and sharing resources so that all citizens can access the information they need.

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IT might seem like a good idea at the time, but a relationship tattoo can turn into a rather unsavoury reminder when things turn sour.
Earlier this week we told how Stephen Bear had his half-heart inking removed a year after getting it done with then-girlfriend Jemma Lucy.
Now bitter exes are sharing the hilarious ways they’ve covered up tattoo tributes to doomed love affairs.
One covered up an etching of their ex by turning it into a gorilla, while another transformed their former lover's face into a demon.
Some were less inventive, simply crossing out their name and, in some cases, replacing it with another.
While one bloke turned his tribute to ex Lauren into the Polo Ralph Lauren symbol.
MOST READ IN LIVING
MIND OVER MATTERWhat are the symptoms of anxiety, how can it be treated and who else suffers? From Zayn Malik to Will Young
BEST VALUE BIRDCheapest Christmas turkey prices revealed - Aldi and Lidl come joint top with £11 birds to feed six people
TAKE A GOOD GANDEROnly one in eight people can spot the fox hiding among the geese in this tricky optical illusion
'I fought cancer by quitting carbs'Father with brain tumour claims high-fat diet is the reason he's still alive
Log offGot a phone call from 'BT' saying scammers are accessing your internet? Here’s why you should hang up immediately
Today we told how a Mike Tyson fan, 18, was scarred after a £9 temporary tattoo turned into a blistered burn.
Earlier this week we reported how a jobseeker was turned down for a job at Costco after a manager spotted a TATTOO on her wrist.


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You want help
If you are between 12 and 19, call us and/or come in to see us. Or we can come to you at your school.
If you are in school, ask your School Counsellor to connect you with us.
If you are a family member who is impacted by your child’s use of alcohol and/or drugs, please call us.

domain: psychology


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Highland games on display at Celtic Festival
SHERMAN, Texas (KXII) -This weekend Sherman celebrated the 5th annual Celtic Festival... and it wouldn’t have been complete without the traditional highland games.
”The festival is really centered around the highland games as well as our pipe and drum competition and our highland dancing,” said Rob Ballew, the founder and director of the Sherman Celtic Festival. “Everything else is extra added bonus.”
From throwing the caber to taking part in the sheaf toss, athletes came out to show off their strength and skills in some of the more uncommon sporting events.
”It’s difficult if you know what you’re doing,” said Ballew. “And it’s really, really difficult if you don’t know what you’re doing.”
”Basically I just started coming to the competitions and learning as much as I could from my fellow competitors,” Elissa Van Vleck, highland games competitor. “So, it’s been a ride ever since then. You learn really quickly that you need a lot of endurance and strength.”
The different type of competition is what what drew several athletes to start taking part in the games.
”Some of the people I know also found highland games as the sport they moved to after they got tired of weightlifting,” said Kimberly Lim. “The sheaf toss is my favorite still. Probably having the Olympic weightlifting background helps a lot and being very tall. Since I’m 6′ 1′' I’m close to the bar than they are.”
”There’s nine events to to choose a favorite is difficult,” said Van Vleck. “But I’ve had a lot of success with the height events, sheaf.”
The highland games community is always looking to grow.
-”Different from other sports, that even though we’re competing against each other, everyone wants to to see you do your best job and will support you and coach you,” said Lim. “That’s what keeps me coming back.”
Those interested in getting involved in competing in the highland games, can reach out to the Sherman Celtic Festival on Facebook and they can put you in contact with a local athlete in Texoma.
Copyright 2022 KXII. All rights reserved.

domain: hobby


Kenya’s Attorney General Githu Muigai said on Thursday that any attempt to hold a parallel swearing in of a president would amount to treason.
Speaking at a news conference, Muigai said that, “The criminal law of the Republic of Kenya stipulates that sort of process is high treason. It is high treason of the person involved, and any other person facilitating that process.” Reuters reports.
Opposition leader Raila Odinga last month said that he would be sworn in as the people’s president on December 12.
Odinga claims he won the August 8 election but was rigged out through manipulation of figures.
“Server indicated that we had 8.8 million votes while Kenyatta had 7.1million votes,” he said.
The Supreme Court annulled the August 8 election citing irregularities, calling for a presidential rerun on October 26, where Uhuru Kenyatta won with 98 per cent.
Odinga did not participate in the repeat election stating that forms had to be made in electoral body for credible election.
The swearing-in, he said, will be based on the results of August 8 presidential election, which he claims he won but was rigged out through manipulation of figures.
While announcing to his supporters last week Tuesday, Odinga said that his inauguration will be like that of Zimbabwe’s Mnangagwa and not of Uganda’s Besigye.


Catholic Church enters a revolutionary period / Garry MacEoin ; interviewed by Byron Bryant. **The
This may not be a complete list of all recordings associated with this subject. Search the entire catalog here.
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|BB1755||The Catholic Church enters a revolutionary period / Garry MacE+2.oin ; interviewed by Byron Bryant.||
Catholic journalist discusses recent changes in Catholicism.
|KPFA, 8 June 1968.|


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Search For "tax"
Updated : 2 weeks, 2 days ago IST
New Delhi [India], February 20 (ANI): Department of Expenditure of Ministry of Finance on Friday released the 17th weekly installment of Rs 5,000 crore to the states to meet the Goods and Services Tax (GST) compensation shortfall.
Updated : 2 weeks, 3 days ago IST
Chandigarh (Punjab) [India], February 19: To promote post-COVID industrial revival and attract greater investment, the Punjab Cabinet led by Chief Minister Captain Amarinder Singh on Friday gave the approval to amend the Industrial and Business Development Policy, 2017, to extend the Goods a
Updated : 2 weeks, 5 days ago IST
Shillong (Meghalaya) [India], February 17 (ANI): Meghalaya Chief Minister Conrad Sangma said on Wednesday that state cabinet has regularised the decisions of the government to revise the tax rates for petrol and diesel taken over the past few days which have led to the reduction in fuel pric
New Delhi [India], February 17 (ANI): Asserting that the central government is committed to bringing natural gas under the Goods and Service Tax (GST) regime, Prime Minister Narendra Modi on Wednesday said that centre plans to spend Rs 7.5 lakh crore on creating oil and gas infrastructure ov
Pune (Maharashtra) [India], February 17 (ANI): Industrial and automotive supplier Schaeffler India has posted 67 per cent jump in its consolidated profit after tax for the December quarter at Rs 142 crore.
Updated : 2 weeks, 6 days ago IST
Gurugram (Haryana) [India], February 16 (ANI): Varun Beverages Ltd (VBL), a key player in the beverage industry and one of the largest franchisee of PepsiCo worldwide, said on Tuesday its losses reduced significantly to Rs 7.24 crore during October to December.
Updated : 3 weeks ago IST
Pune (Maharashtra) [India], February 16 (ANI): Maharashtra Goods and Services Tax (GST) officials have arrested a businessman from Pune for issuing bogus invoices amounting to Rs 110 crores. He has been sent to judicial custody till February 25.
New Delhi [India], February 15 (ANI): The Department of Expenditure under the Ministry of Finance has released the 16th weekly instalment of Rs 5,000 crore to the States on Monday to meet the Goods and Services Tax (GST) compensation shortfall.
Indore (Madhya Pradesh) [India], February 15 (ANI): Associated Alcohols and Breweries Ltd has reported 58 per cent hike in its profit after tax of Rs 25 crore for the quarter ended December.
Updated : 3 weeks, 2 days ago IST
Hyderabad (Telangana) [India], February 13 (ANI): Amara Raja Batteries Ltd (ARBL) is setting up a 50 megawatt solar power plant in Chittoor district of Andhra Pradesh at a total outlay of Rs 220 crore to support its sustainability initiatives.
New Delhi [India], February 13 (ANI): Mini-ratna public sector enterprise Ircon International on Saturday reported 35 per cent hike in its profit after tax at Rs 103 crore as against Rs 76 crore in Q2 FY21.
New Delhi [India], Feb 13 (ANI): Max Ventures and Industries Ltd (MaxVIL) has reported 10 per cent year-on-year jump in consolidated revenue at Rs 296 crore for the quarter ended December (Q3 FY21).


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The performance of your car is highly dependent on the exhaust manifold, as it helps to effectively regulate the movement and volume of gases that travel through it. Exhaust manifolds are essential components in any vehicle’s engine, providing a path for exhaust gasses to exit safely and efficiently.
Without a properly functioning manifold, your car can suffer from reduced power output and fuel economy. It is therefore important to understand the importance of having an adequately working exhaust manifold to ensure optimal performance from your vehicle’s engine.
This article will discuss how an efficient exhaust manifold works, what effects its failure can have on a car’s performance, and provide tips on how best you can maintain it.
What is an Exhaust Manifold?
An exhaust manifold is an important component of a vehicle’s engine that facilitates the flow of exhaust gases from the various cylinders to the main outlet. It is composed of several pipes or tubes connected, with each pipe leading from a cylinder head to one main tube.
The manifold also has flanges or bolts connecting it to other components such as headers and catalytic converters. This allows for efficient distribution of heat and improved overall performance.
Exhaust manifolds are designed with specific materials, sizes, shapes, and configurations to optimize their function within each car model’s specific design parameters.
Drivers need to take proper care when selecting an exhaust manifold since they play a crucial role in any vehicle’s performance capabilities. Improperly fitted manifolds can lead to reduced power output, increased fuel consumption, decreased torque, and even damage parts like gaskets due to improper alignment or fitment issues.
Making sure that you have chosen the right size and compatible material will help ensure maximum performance potential as well as reduce long-term maintenance costs associated with your car’s engine system over time.
How Does an Exhaust Manifold Enhance Performance?
An exhaust manifold is a crucial component of any car engine. It is responsible for collecting the exhaust gases that are generated during the combustion process and redirecting them out of the vehicle. This helps to increase performance by reducing back pressure and improving overall flow rates.
In addition to this, an exhaust manifold also serves as a heat exchanger; it absorbs some of the thermal energy from the hot gasses being expelled out of your engine and converts it into usable power.
This extra power can help give your car better acceleration, higher top speeds, improved fuel economy, and reduced emissions levels too. Overall, installing an optimized exhaust manifold system in your car can make a big difference when it comes to driving performance!
Do I Need to Upgrade My Exhaust Manifold for Better Performance?
When it comes to your car’s performance, the exhaust manifold is an essential component. It collects and directs the hot gases from the engine cylinders to ensure they are dispersed properly out of the exhaust system. An upgraded exhaust manifold can provide more power and torque, resulting in improved acceleration and fuel economy.
It’s important to consider whether you need an upgrade before making a purchase though – if your existing manifold is performing efficiently then there may be no need for a new one. If you’re looking for better performance or efficiency, however, investing in an upgraded model could be beneficial.
Factors such as age, condition, and how much use it gets should all be taken into account when deciding on whether to replace or upgrade your current unit.
Upgrading your exhaust manifold can also bring other benefits including increased durability due to its strengthened construction, improved sound characteristics thanks to larger diameter pipes that reduce back pressure and allow greater flow rates, plus reduced emissions with some models designed specifically for this purpose.
However, these advantages come at a cost so it’s important to weigh up both sides before making any decisions about upgrading your existing model
Exhaust manifolds and headers are essential for your car’s performance, as they help to improve the flow of exhaust gases from the engine. For a good place to look for exhaust manifolds, be sure to check out SuncentAuto’s high-performance exhaust manifolds & headers.
With their durable construction and superior design, these parts can provide improved power output while reducing emissions. Additionally, they come with easy installation instructions so you can quickly upgrade your car’s performance without any hassle. Investing in quality aftermarket exhaust components is one way to ensure optimal performance from your vehicle.


Hulk Hogan has said he is concerned about his Florida home in Clearwater Beach after BP’s oil spill. He told Life & Style magazine: “No one can give us a straight answer. Now that it’s hurricane season, the big unknowns are coming at us. How far is the oil going to spread? Is it going to push way up on the land? … The local economy depends on tourism. All of a sudden the tourists aren’t here. And I’ve seen the price of [seafood] skyrocketing, because we depend on most of the grouper and the shrimp.”
On a side note, Hulk Hogan and Eric Bischoff did not attend last night’s TNA Victory Road PPV.
(credit: The Wrestling Globe Newsletter)


A traditional English folk song melody arranged for solo piano. Nostalgic, gentle and pensive. This track is perfect for underscoring an emotional montage or character's reflection on their life for a narrative project.
|Full Track (01:39)||$39.95||Add To Cart|
A pretty little solo performed on classical piano. This track was written for a beautiful French girl and it conveys a sense of falling in love. Reflective, nostalgic and sentimental.
BPM 113: Take a nice walk and put all thoughts of stress and the day's troubles aside. This simple and outdoorsy piece exudes a spirit of positivity. A very pleasant track for underscoring a wide variety of projects.
A solo piano piece that is sentimental, thoughtful and emotional. The piece builds gradually into a climax, then falls towards the end. A great piece for conveying a sense of peace, resolution or acceptance.
BPM 90: A track featuring a smooth and hopeful piano solo. Romantic, nostalgic and relaxing. This piece would be well suited for underscoring scenes of forgiveness, understanding, and compassion.
BPM 128: A relaxing solo piano piece. The gentle and smooth melody will create feelings of nostalgia and warmth. Great for any dramatic or emotional project.
This piano ballad has a dark and unresolved mood. Atmospheric, serious and uncertain. Convey feelings of hopelessness and underscore a character's emotional struggle with this track.
A warm and flowing solo piano track. This piece creates the feeling of a journey completed, and ends with a positive resolution. Reflective, emotional and elevating.
Tender, loving and simple. This solo piano ballad feels very nostalgic and longs for simpler days. A beautifully spacious and down tempo track.
BPM 80: An original composition for solo piano. A slow and pensive track that invokes images of night time and of the dawn that follows. A bohemian lifestyle, the long walk home, and a Parisian backdrop. This track would also be ideal for themes of coming to terms with loss and/or regret.
BPM 93: Deep, sincere and authentic. Let your mind dig into the depths of your soul as this track's melody gently leaves its moody impression. A soft piano combined with a subtle string section fills out the arrangement nicely.
BPM 90: A piano centered track that is thoughtful and delicate. A film-like piece which evokes thoughts childhood and growing up. Sensitive, touching and moving.
The most famous ragtime piano song by Scott Joplin, recorded with a real upright jazz piano in order to preserve the natural color of that old Jazz sound. Features a club recording environment and a very dynamic playing, where soft parts alternate with joyful, hammering notes. Perfect for funny videos, vintage, old fashioned or cheerful contents, cartoons, trailers or films for kids. Carefree and jazzy, this song is guaranteed to spice up and give fuel to any video production!
BPM 120: A soothing and gentle piano piece. This relaxing track conveys feeling of nostalgia, romance and sadness. Well suited for any narrative project where a character faces heartache or loss.
BPM 120: A simple, innocent opening develops into a dramatic and passionate crescendo. This piece is an optimistic homage to human achievement about defeating adversity and overcoming hardship. Inspirational, positive, and hopeful.
BPM 126: Hopeful, liberty, brightness. A delicate, beautiful and warm melodic progression on piano. Looking on the bright side of things and moving forward.
BPM 80: A mellow and evocative ballad that comes straight from the heart. This soft piano piece is evocative of loving relationships and deep connections. Romantic, nostalgic and wistful.
Light, nostalgic, and lovely. This upbeat piano ballad is what one might hear on a sunny day while taking a stroll in the park. Upbeat, classy, and light.
BPM 72: This soulful track features a simple and beautiful piano nocturne. Elegant, simple and relaxed. This track evokes feelings of loss, love and reflection.


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The variety of terrorist incidents in 2020, as much as November 15, decreased by 63.93 per cent as in comparison with the corresponding interval in 2019 in Jammu and Kashmir, in accordance with the Ministry of House Affairs (MHA). The Ministry knowledgeable that there was additionally a lower in fatalities of Particular Forces Personnel by 29.11 per cent and a lower in casualties of civilians by 14.28 per cent in 2020 (as much as November 15, 2020) as in comparison with the corresponding interval in 2019.
The house ministry whereas giving a short about annual achievements additionally mentioned that Adaptation of Central Legal guidelines and State Legal guidelines within the Union Territory of Jammu and Kashmir and the Union Territory of Ladakh is without doubt one of the key achievements of the Central authorities.
“Orders have been notified for adaptation of 48 Central Legal guidelines and 167 State Legal guidelines in respect of UT of J&Ok. Orders referring to adaptation of 44 Central Legal guidelines and 148 State Legal guidelines in UT of Ladakh have been additionally notified,” MHA mentioned.
“The Jammu and Kashmir Reorganisation (Elimination of Difficulties) Order, 2020 was notified on 31.03.2020. It removes difficulties with regard to part 75 of the Jammu and Kashmir Reorganisation Act, 2019 for administering oath to new judges appointed to the widespread Excessive Court docket for Jammu and Kashmir and Ladakh. A Bench of Central Administrative Tribunal was established at Jammu on 08.06.2020,” MHA has mentioned.
The MHA additionally mentioned that one-time monetary help of Rs 5.5 lakh per household offered to 36,384 displaced households from Pakistan occupied Jammu and Kashmir and Chhamb underneath the Prime Minister Improvement Package deal.
One-time monetary help on the fee of Rs 5.5 Lakh per household for the 5,764 households of West Pakistan Refugees (WPRs) in Jammu and Kashmir can be being offered at par with displaced individuals of PoJK and Chhamb, it mentioned.
In 2019, the Central authorities revoked Article 370 which gave particular provisions to the erstwhile state of Jammu and Kashmir.
The federal government bifurcated Jammu and Kashmir into two Union Territories- Jammu and Kashmir and Ladakh.
(With inputs from ANI)
Newest India Information


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On Wednesday 22 November, the Government released their Autumn Statement detailing the new measures being put in place.
We wanted to put together a round-up of some of the measures that might affect you, however you can read the full statement here: https://www.gov.uk/government/publications/autumn-statement-2023
Universal Credit and Tax Credits
From April 2024, most benefits and Tax Credits in England and Wales will increase by 6.7%, in line with September’s inflation. This could see an average increase of £470 a year for millions of households.
State pension payments will rise by 8.5% which means millions of people will receive a weekly increase of up to £17.35 from April 2024.
Employees and self-employed workers will pay less in national insurance from next year.
For employees, the rate of national insurance paid on earnings of between £12,570 and £50,270 a year will be cut from 12% to 10%.
This is expected to benefit around 27 million employees and means the average worker on a salary of £35,500 will save £450 over the 2024/25 tax year.
For self-employed workers, ‘class 4’ contributions will be cut from 9% to 8%, and mandatory ‘class 2’ contributions will be scrapped.
Around two million self-employed workers will pay less national insurance and the average self-employed working, earning £28,200 a year, will pay £350 less than they did this year.
National Minimum Wage
From April 2024, lower paid workers will benefit from a boost in their wages.

domain: politics


Opposition senators want to know: Why is the government appointing a drug lord to negotiate with the Maute Group, which is behind the months-long Marawi siege?
“Akala ko ba galit ang administrasyon sa iligal na droga pero bakit nila hinahayaan ang isang drug lord para makipagnegosasyon sa Maute group?” said Partido Liberal president, Sen. Francis “Kiko” Pangilinan, referring to former Marawi City mayor Omar Solitario Ali.
Last June 23, or a month into the Marawi siege, the Philippine National Police Drug Enforcement Group (PNP-DEG) in Mindanao recovered two kilograms of shabu worth about P10 million and other drug paraphernalia at Solitario Ali’s house in Barangay Bangon, Marawi.
Solitario is included in Duterte’s list of narco-politicians. He is also accused of being a financier of the Maute group.
Defense Secretary Delfin Lorenzana, who is also the concurrent martial law administrator, said he ordered the removal of Solitario Ali from the list of persons ordered arrested under martial law for alleged rebellion as recommended by Peace Adviser Secretary Jess Dureza.
“Kung prayoridad ng administrasyon ang gera kontra droga, dapat managot ang lahat ng may kinalaman sa drug trade, pati ang mga kaalyado ng Presidente,” Sen. Bam Aquino added.
Aquino insisted that the government should be transparent in its dealings with Solitario Ali so he will not escape liability in connection with his illegal drugs case.
“We are willing to accept any help that the government can get to end the Marawi siege once and for all. However, this should not be used as reason to exonerate Solitario of the rebellion and drug charges filed against him,” said Senate Minority Leader Sen. Frank Drilon.
Furthermore, he said cases filed against Solitario should be pursued to prove that the government is serious in prosecuting those involved in illegal drugs.
23 June 2017
Police recover P10-M shabu from ex-Marawi mayor’s house
10 September 2017
Duterte confirms ex-Marawi mayor on narco-list negotiating with Maute


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Optimization of optical gain in composite materials containing Rh6G dye and gold nanoparticles
2015 (English)In: Asia Communications and Photonics Conference, ACPC 2015, 2015Conference paper (Refereed)
The existence of metal nanoparticles in a dye material can lead not only to quenching or enhancement of dye luminescence, or random lasing action, but also to the change of the fundamental material characteristic as optical gain. © 2015 OSA.
Place, publisher, year, edition, pages
IdentifiersURN: urn:nbn:se:kth:diva-195162ScopusID: 2-s2.0-84971656710ISBN: 9781943580064OAI: oai:DiVA.org:kth-195162DiVA: diva2:1045007
Asia Communications and Photonics Conference, ACPC 2015, 19 November 2015 through 23 November 2015
Conference Paper. QC 201611082016-11-082016-11-022016-11-08Bibliographically approved

domain: chemistry


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I finally decided to trade in my point-and-shoot for a DSLR camera. I narrowed my choices down to the Nikon J1 and the Nikon D3100. I liked the sleek design of the J1 but the reviews weren't great so I went with the D3100. I have been reading tutorials and trying to get out of shooting in automatic mode, and while I haven't even figured out a fraction of what this thing can do, I am absolutely loving it. I don't think I quite realized how poor of quality my pictures were before. Hopefully, from now on, all my pictures on my blog will be better and will continue to improve. Here are a few pictures that I have taken...
My Shih-tzu Zhoe
Sweet baby Presleigh
Playing with depth of field
Now that I can finally take decent pictures, I will be posting pictures of my office make-over very soon!
I have always loved the Aviator coffee table trunk from Restoration Hardware. I thought this piece would be perfect for an interior design project that I am working on, but with a price tag of over $1000 and the fact that it is no longer available, it wasn't an option. Instead I decided to try my hand at a DIY replica. I found an old foot locker at the thrift store for $9.99. The hardware was already a gold that was very similar to my Restoration Hardware inspiration. I taped over it so that it wouldn't be covered with paint. I used metallic silver spray paint to cover the rest of it (it was green before). When I removed the tape, I was so surprised at how similar it looked to the RH trunk. It is much smaller and is being used on the hearth, not as a coffee table, but I absolutely loved the end results. Now I want to do one for my own house but I get bored doing the same projects again and again, so we'll just have to see about that.
Restoration Hardware Aviator Coffee Table compared to DIY foot locker
'Tis the season for babies! I know quite a few people that are expecting little ones within the next couple of months, two of which are girls. I decided to make these door hangers for part of their baby shower gifts. They can be hung on the door of the hospital and then transferred to the front door of the home of the baby's nursery. My favorite part is the little curls on top that I made out of wire, and of course, the girly pink satin ribbons. Speaking of people having babies, my very best friend in the whole world just found out she is pregnant too! I am beyond excited and have already started designing her nursery!
She is going to be the cutest pregnant woman ever!

domain: design


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— Seth Grahame-Smith, Abraham Lincoln: Vampire Hunter
„I'm gonna barf," I whispered to Fang, wiping my sweaty hands on my jeans.
You'll be fine," he whipered back. "You always are.
I'm gonna die," I moaned.
You can't die," he said a hint of a smile in his voice."You're the indesructible Max.“
— James Patterson American author 1947
„Look baby, this is simple. You can't see? You're fucking with me? You're fucking with a P. I. M. P.!“
— 50 Cent American rapper, actor, businessman, investor and television producer 1975
„"I'm scared of him," said Piggy, "and that's why I know him. If you're scared of someone you hate him but you can't stop thinking about him. You kid yourself he's alright really, an' then when you see him again; it's like asthma an' you can't breath. I tell you what. He hates you too, Ralph —"
"Me? Why me?"
"I dunno. You got him over the fire; an' you're chief an' he isn't."
"But he's Jack Merridew!"
"I been in bed so much I done some thinking. I know about people. I know about me. And him. He can't hurt you: but if you're standing out of the way he'd hurt the next thing. And that's me."
"Piggy's right, Ralph. There's you and Jack. Go on being chief."“
— William Golding British novelist, poet, playwright and Nobel Prize for Literature laureate 1911 - 1993
Ch. 5: Beast from Water
„"Amazing. You're here, but you can't do a simple thing like raising light, or do I mean lazing right? Whichever. You can't. Why not?"
"No one ever showed me how," I said.
He swayed about, looking solemn. "I quote," he said. "I'm very well read in the literature of several worlds, you know, and I quote. What do they teach them in these schools?"“
— Diana Wynne Jones English children's fantasy writer 1934 - 2011


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This is what it’s all about ladies and gents.
Foothill High School in Palo Cedro, California displayed the ultimate show of respect for one of their own whos job is to cheer them to victory each and every game. Ashley Adamietz, a cheerleader at Foothill High School was diagnosed with leukemia last month.
This past Friday before the varsity football team played their game, each player on the team was holding an orange rose when they made their way onto the field. The color orange is the color associated with Leukemia Awareness. Each player passed by Adamietz and placed the rose they were holding at her feet. The crowd cheering in the background added something more special to any already special moment on the football field.
Que the goosebumps…
Adamietz took to her Twitter account the day after and expressed how much that special moment meant to her.
I don’t know where I’d be without the support of my family, friends and most importantly, my school❤? pic.twitter.com/7vCFszFfoD
— Ashley Adamietz (@atrathen101) September 3, 2016
It’s stories like these that there aren’t enough of in the world. Such a small gesture from a football team that ended up being an even bigger moment for the person that the gesture was intended for.
Kudos to the Foothill High School football team for what they did for one of their own.