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The number of ambulatory procedures has increased in the last two decades, primarily owing to rapid medical advances and the desire for cost savings. One vital improvement is the development of anaesthetic agents that maintain stable surgical conditions while allowing a more rapid recovery of consciousness with minimal side-effects.1 Sevoflurane and desflurane are two of the most widely used volatile anaesthetic agents for ambulatory procedures because of their ideal pharmacokinetic properties and few adverse effects. Factors that may be related to delayed discharge or even unwanted admission include cognitive and cardiovascular recovery, postoperative nausea and vomiting (PONV), postoperative pain and respiratory complications.2–4 Among these factors, respiratory complications might be the most serious.
The solubility of desflurane in the blood is lower than that of sevoflurane.5 This results in faster induction and awakening from anaesthesia.5 However, the irritant properties of desflurane on the airway may provoke increased secretions, coughing, laryngospasm and breath-holding.6 Accordingly, desflurane is contraindicated for inhalational induction in children.7,8
Nonetheless, an increasing number of studies comparing respiratory events between sevoflurane and desflurane-based anaesthesia have concluded that desflurane does not cause significantly more adverse upper airway events than sevoflurane.9–11 Therefore, this systematic review and meta-analysis of randomised controlled clinical trials (RCTs) aimed to compare differences in the incidence of adverse respiratory events in ambulatory surgery between sevoflurane and desflurane-based anaesthesia.
Materials and methods
Protocol and eligibility criteria
This systematic review and meta-analysis was performed in accordance with the criteria outlined in the PRISMA guidelines.12 The summary of the PICOS framework that was used to determine eligible articles with primary and secondary outcomes is summarised in Table 1.
Table 1 -
PICOS framework for studies included in the qualitative synthesis and meta-analysis
||Adults or children, elective ambulatory or outpatient surgery, receiving general anaesthesia, nonsedation procedure
||Maintenance with desflurane
||Maintenance with sevoflurane
||Primary: adverse respiratory events, including airway irritation, stridor, coughing, respiratory distress, and laryngospasm occurred from intubation to extubation
||Secondary: emergence agitation, postoperative nausea and vomiting, time to eye open, and time to discharge from the operation room
||Randomised controlled trials with full text in English
Search strategy and study selection
We searched PubMed, Medline, Cochrane Central Register of Controlled Trials, ScienceDirect and Embase databases for qualifying studies that were published up to 30 June 2019 using the following search terms: sevoflurane, desflurane, ambulatory and outpatient. We did not search for ongoing trials, nor proceedings of major annual meetings of anaesthesiology societies.
Two independent reviewers initially screened the titles and excluded duplicated studies or studies that did not meet the eligibility criteria. Studies listed in related systematic reviews or meta-analyses were also screened. A third reviewer was consulted in the event of any disagreements between the first two independent reviewers. The remaining articles were screened by reading the abstract, and potentially eligible trials were analysed in detail by reading the full text. Retrospective studies, case reports, non-English studies, unpublished trials and studies that did not investigate respiratory outcomes were excluded from our analysis.
The full texts of included studies were reviewed by two independent authors. We extracted the following data from the identified articles that met all inclusion criteria: the first author's name, year of publication, type of study, type of surgery, participants’ age (adult or child), number of cases in the sevoflurane and desflurane groups, types of intra-operatively accessed airways (mask, laryngeal mask airway or endotracheal tube), special prescription to treat coughing (e.g. fentanyl), PONV and PONV-related factors (e.g. nitrous oxide and prophylactic antiemetics), adverse respiratory outcomes, outcomes related to recovery (time to eye opening, time to discharge from the operation room) and nonrespiratory outcomes (emergence agitation and PONV).
We assessed the risk of bias by using the Revised Cochrane risk of bias tool for randomised trials (RoB 2.0) that was updated in October 2018.13,14 This tool assesses the risk of bias via the following six different criteria: allocation bias (bias arising from the randomisation process), performance bias (due to deviation from intended interventions), attrition bias (due to missing outcome), measurement bias (bias in measurement of the outcome), reporting bias (in selection of the reported results) and overall judgement. The two reviewers independently performed the assessment.
The major outcome recorded was the occurrence of adverse respiratory events, including airway irritation, stridor, coughing, respiratory distress and laryngospasm. According to each trial's design, all of the respiratory events recorded in the desflurane or sevoflurane groups from induction to extubation were included. Secondary outcomes consisted of emergence agitation, PONV, time to eye opening and time to discharge from the operation room. The definition of emergence agitation depended on the study design of each study and included the incidence of confusion or drowsiness on emergence, 3 or 4 points on the four-point emergence scale, and 4 or 5 points on the five-point agitation score. PONV was recorded, including when it occurred in the postanaesthesia care unit (PACU) and if an antiemetic was given. Nausea took priority over vomiting if they occurred separately during the postoperative period. Time to eye opening was measured as the time elapsed between discontinuing the volatile anaesthetic to the time of eye-opening. Time to discharge from the operation room was measured as the time that elapsed between arrival in the PACU until the time that the criteria for discharge were met. The criteria for discharge depended on each study's design. Study authors were contacted to provide missing data from eligible studies
The pooled relative risk (RR) for binary outcomes and the weighted mean difference for continuous outcomes were calculated in this meta-analysis. We obtained standard deviations by dividing the interquartile range by 1.35 and assumed that the median and mean values were identical under a strong assumption of normal distribution. A value of 0.5 was added to each zero cell when the outcome was binary and a zero cell appeared.15 The data from individual studies were pooled using the DerSimonian and Laird random effect model.16 The pooled estimates in the child and adult cohorts were compared using a mixed effects model. Next, we performed a subgroup analysis according to several characteristics [the assessed risk of bias, adding fentanyl or not and bispectral index (BIS)] using a mixed effect model to measure the primary outcome (the adverse respiratory events). Interstudy inconsistency was assessed using the I2 statistic; a value more than 50% indicated substantial heterogeneity.17,18 Publication bias was detected by a funnel plot19 and an Egger's test.20 A sensitivity analysis that evaluated the impact of individual studies was performed by excluding each study one at a time, and the pooled effect size was re-estimated. The risk of bias assessment was performed using Review Manager (RevMan) computer program, version 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014), and the quantitative meta-analysis was conducted using Comprehensive Meta-Analysis version 3.3.070 (Biostat, USA).
A Trial Sequential Analysis (TSA) was performed to further validate the primary and secondary outcomes in the context of information size and effect size using TSA software version 0.9.5.10 beta. The effect size was calculated using the empirical estimate, and conclusions were made according to the following three conditions: required information size, whether the monitoring boundary was crossed and whether the futility boundary was crossed.21,22 Analyses were two-sided, and the alpha level was set at 5%. In addition, the power was set at 80% in the TSA.
Summary of findings
To assess the quality of the body of evidence associated with the main outcomes, including adverse respiratory events, emergence agitation, PONV, time to eye opening and time to discharge from the operation room, data were exported from Review Manager 5.2 to Guideline development tool (GRADEpro GDT) to create the ‘summary of findings’ table for the main outcomes. The summary of findings (SoF) was constructed using the GRADE software (Supplemental Table 1, http://links.lww.com/EJA/A409).
Our search strategy yielded a total of 172 trials, including 163 from medical databases and nine from references of previous studies related to our topic. The results did not include registered ongoing trials nor the proceedings of major annual meetings of anaesthesiology societies. After removing duplicates, unpublished trials and articles that did not meet the inclusion criteria based on their title or abstract, we identified 28 potentially eligible publications. Among them, six non-English studies were excluded. After analysing the full text, nine studies that did not investigate respiratory outcomes were also excluded. Thus, 13 randomised controlled trials met our inclusion criteria and were included in our analysis. The search strategy and exclusion process are shown in the flowchart (Fig. 1). Overall, 1267 patients were randomised to receive desflurane or sevoflurane-based anaesthesia (634 and 633 patients, respectively). The characteristics and overview of the selected publications are summarised in Table 2.
Table 2 -
Study characteristics included in the meta-analysis
|Mahmoud et al.24
||Gynaecological day-case surgery
||31 vs. 29
||Induction 50 μg
|Eshima et al.27
||63 vs. 64
||Incidence of respiratory events
||Intra-operative (dose varieda)
|Saros et al.28
||35 vs. 35
||Induction 100 μg
|White et al.35
||Superficial noncavitary procedure
||65 vs. 65
||Overall incidence of coughing
|Jindal et al.30
||Outpatient laparoscopy gynaecology surgery
||50 vs. 50
||Early recovery time
||Induction 2 μg kg−1
|De Oliveira et al.25
||Outpatient gynaecological hysteroscopy
||40 vs. 40
||Time to awakening
||Maintenance 25 μg every 5 min
|Oofuvong et al.33
||Ambulatory urologic surgery
||68 vs. 68
||Incidence of emergence agitation
||Intra-operative 0.5 to 1 μg kg−1
|Werner et al.34
||Ambulatory urological cystoscopy
||34 vs. 32
||Mean time to eye-opening,
||Induction 1 to 2 μg kg−1
|Dalal et al.26
||Hysteroscopic gynaecological surgery
||45 vs. 47
||Adverse airway events
||Premedication 1 μg kg−1
|Kim et al.23
||Ambulatory strabismus surgery
||100 vs. 100
||Overall incidence of adverse respiratory events
|Kotwani et al.31
||Ambulatory lower abdominal surgery
||30 vs. 30
|Kurhekar et al.32
||34 vs. 33 vs. 33
||Time from immediate recovery to home readiness
||Induction 2 μg kg−1
|Jadhav et al.29
||Elective short surgical procedures
||40 vs. 40
||Early postoperative recovery profile
||Premedication 2 μg kg−1
Eshima et al
: The attending anaesthesiologist added fentanyl to the induction regimen based on clinical circumstances. Total mean ± SD intra-operative fentanyl use was 141 ± 108 μg in Desflurane group and 129 ± 118 μg in Sevoflurane group.
bBaxter: Baxter Healthcare Corporation, Deerfield, Illinois, USA.
cFaculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
Risk of bias
Only two trials met the criteria for low risk of bias.23,24 Six trials reported random sequence generation and allocation concealment,23–28 while seven trials did not describe allocation concealment.29–35 In all of these trials, the clinician who administered the anaesthesia was aware of the type of volatile anaesthetic that was administered, while another individual, who was unaware of the type of anaesthetic that was administered, was responsible for the recording. Two trials had a high risk of performance bias because they lacked a rigid study protocol that may have affected the intra-operative judgement of the anaesthesiologist who was aware of the type of anaesthetic that was administered.26,27 There was a low risk of performance bias in five trials because of the rigid study protocol, participant adherence, controlled concentration and monitored depth of the volatile anaesthetic.24,32–34 One trial did not meet the criteria for low risk with regard to attrition bias.34 One trial had a high risk of measurement bias because the intra-operative measurement was performed by unblinded anaesthetists. Two trials may have had slight measurement bias because it was unclear whether the outcome measurements were recorded by the blinded individuals.28,30 Four trials did not meet the criteria for low risk of reporting bias because some measurements in the “Materials and Methods” section were not completely reported.25,28,32,35 One trial had a high risk of reporting bias because the data and units in the figure legends and description of the results were inconsistent after the units were converted.25 With respect to the above potential biases, four trials had a high risk of bias,25–27,31 while most trials had either a low or unclear risk of bias (Figs. 2 and 3).
Primary outcome: adverse respiratory events
A total of 13 trials with 1267 patients receiving desflurane or sevoflurane-based anaesthesia (634 and 633 patients, respectively) were analysed. Results from the pooled analysis revealed that the occurrence of adverse respiratory events was significantly higher in the desflurane group than in the sevoflurane group (20.0 vs. 12.8%, RR 1.59 (95% CI 1.15 to 2.20), Fig. 4). There was low heterogeneity (I2 = 20%) among the studies. In addition, the pooled estimates in the adults’ and children's cohorts were not significantly different (P for heterogeneity = 0.500). The funnel plot revealed some asymmetry with a significant Egger's test (P = 0.039; Supplemental Figure 1, http://links.lww.com/EJA/A410). In addition, the conclusion was not altered when any single study was excluded (data not shown). The TSA revealed that the cumulative Z-curve shortly crossed the trial sequential monitoring boundary but did not exceed the estimated information size. Therefore, the chance of false-positive result may be decreased but it still may exist, and more trials should be included to confirm our findings (Supplemental Figure 2, http://links.lww.com/EJA/A411). The quality of the evidence of adverse respiratory events was low according to the GRADE evaluation (Supplemental Table 1, http://links.lww.com/EJA/A409).
We further conducted a subgroup analysis of 10 trials that included fentanyl prescriptions and three trials that did not include fentanyl. The result showed no significant difference between these two pooled effect sizes (P for heterogeneity = 0.447; Supplemental Figure 3, http://links.lww.com/EJA/A412), indicating the observed effect was similar between the trials with fentanyl prescriptions (13.9 vs. 7.3%, RR 1.79 (95% CI 1.14 to 2.81), I2 = 0%) and those trials without fentanyl prescriptions (33.8 vs. 25.1%, RR 1.39 (95% CI 0.87 to 2.22), I2 = 60.8%). We also conducted a subgroup analysis of 10 trials that included adults and three trials that included children. The result showed no significant difference between these two pooled effect sizes (P for heterogeneity = 0.500; Fig. 4), indicating the observed effect was similar between the adults (14.9 vs. 8.0%, RR 1.75 (95% CI 1.14 to 2.71), I2 = 0%) and the children (31.3 vs. 23.2%, RR 1.40 (95% CI 0.86 to 2.29), I2 = 62.5%). An additional subgroup analysis of the primary outcome (adverse respiratory events) according to the assessed risk of bias (low vs. high or unclear risk) was performed, and the pooled effect size was substantially smaller in the two studies with lower risk of bias than the pooled effect size in the 11 studies with higher or unclear risks of bias (P for heterogeneity = 0.017; High or unclear risk group: 16.1 vs. 7.7%, RR 1.95 (95% CI 1.36 to 2.80), I2 = 0%; Low risk group: 35.1 vs. 32.6%, RR 1.08 (95% CI 0.77 to 1.50), I2 = 0%; Supplemental Figure 4, http://links.lww.com/EJA/A413). The subgroup analysis of the BIS group and non-BIS group showed that, in the BIS-guided subgroup, there were significantly more adverse respiratory events in the desflurane group (non-BIS group: 18.6 vs. 13.5%, RR 1.24 (95% CI 0.95 to 1.63), I2 = 13.3%; BIS group: 25.2 vs. 10.2%, RR 2.36 (95% CI 1.36 to 4.09), I2 = 0%; P for heterogeneity = 0.042, Supplemental Figure 12, http://links.lww.com/EJA/A421).
We analysed emergence agitation in five trials that included 626 patients who were administered desflurane or sevoflurane-based anaesthesia (313 patients each). Results from the pooled analysis revealed that there was no significant difference in the occurrence of emergence agitation between the desflurane and sevoflurane groups: 29.1 vs. 27.2%, RR 1.05 (95% CI 0.84 to 1.30), and the heterogeneity was low (I2 = 0%) (Fig. 5). In addition, the pooled estimates in the adults’ and children's cohorts were not significantly different (P for heterogeneity = 0.602), indicating that the observed effect was similar between the adults and the children. The funnel plot revealed some asymmetry with a significant Egger's test (P = 0.032; Supplemental Figure 5, http://links.lww.com/EJA/A414). In addition, the conclusion was not altered when any one of the single studies was excluded (data not shown). We were unable to calculate the boundary TSA, which was ignored due to too little information (3.56%). The quality of the evidence of emergence agitation was low according to the GRADE evaluation (Supplemental Table 1, http://links.lww.com/EJA/A409).
Postoperative nausea and vomiting
We analysed PONV in nine trials that included 989 patients who were administered desflurane or sevoflurane-based anaesthesia (494 and 495 patients, respectively). There was no significant difference in the incidence of PONV between the two volatile anaesthetics (19.0 vs. 21.0%, RR 0.95 (95% CI 0.71 to 1.26)), and the heterogeneity was low (I2 = 0%) (Fig. 6). In addition, the pooled estimates in the adults’ and children's cohorts were not significantly different (P for heterogeneity = 0.249), indicating that the observed effect was similar between the adults and the children. The funnel plot was generally symmetric with a nonsignificant Egger's test (P = 0.985; Supplemental Figure 6, http://links.lww.com/EJA/A415). In addition, the conclusion was not altered when any one of the single studies was excluded (data not shown). The quality of the evidence of PONV was low according to the GRADE evaluation. The TSA demonstrated that the cumulative Z-curve did not cross the trial sequential monitoring boundary and the estimated information size; therefore, our analysis may have generated false-negative findings, and more trials should be included to confirm our conclusions (Supplemental Figure 7, http://links.lww.com/EJA/A416). The subgroup analysis of the prescription of nitrous oxide or prophylactic antiemetics did not change the main finding (data not shown).
Time to eye opening
We analysed the time to eye opening in 11 trials that included 1070 patients who were administered desflurane or sevoflurane-based anaesthesia (536 and 534 patients, respectively). The time to eye opening was significantly shorter in the desflurane than in the sevoflurane group (mean difference = −3.32 min (95% CI −4.02 to −2.61), Fig. 7), and the heterogeneity was substantial (I2 = 72.6%). In addition, the pooled estimates in the adults’ and children's cohorts were not significantly different (P for heterogeneity = 0.506), indicating the observed effect was similar between the trials. The funnel plot revealed some asymmetry with a borderline significant Egger's test (P = 0.055; Supplemental Figure 8, http://links.lww.com/EJA/A417). In addition, the conclusion was not altered when any one of the single studies was excluded (data not shown). The TSA indicated that the cumulative Z-curve crossed the trial sequential monitoring boundary and exceeded the estimated information size; therefore, our conclusion was sufficient and no more trials are needed to confirm our conclusions (Supplemental Figure 9, http://links.lww.com/EJA/A418). The quality of the evidence of time to eye opening was very low according to the GRADE evaluation (Supplemental Table 1, http://links.lww.com/EJA/A409).
Time to discharge from operation room
We analysed the time to discharge from the operation room in 10 trials that included 1055 patients who were administered desflurane or sevoflurane-based anaesthesia (528 and 527 patients, respectively). There was no significant difference in the time to discharge from the operation room between the two anaesthetic agents (mean difference = -0.45 min, 95% CI -5.89 to 4.99), and the heterogeneity was substantial (I2 = 91.5, Fig. 8). In addition, the pooled estimates in the adults’ and children's cohorts were not significantly different (P for heterogeneity = 0.719) indicating the observed effect was similar between the trials. The funnel plot was generally symmetric with a nonsignificant Egger's test (P = 0.985; Supplemental Figure 10, http://links.lww.com/EJA/A419). In addition, the conclusion was not altered when any one of the single studies was excluded (data not shown). The quality of the evidence of time to discharge from the operation room was very low according to the GRADE evaluation (Supplemental Table 1, http://links.lww.com/EJA/A409). The TSA showed that the cumulative Z-curve did not cross the trial sequential monitoring boundary and the estimated information size; therefore, our analysis may have generated false-negative findings, and more trials should be included to confirm our conclusions (Supplemental Figure 11, http://links.lww.com/EJA/A420).
The number of ambulatory procedures has rapidly increased over the past few decades. Sevoflurane and desflurane are the two most popular volatile anaesthetics used during ambulatory surgery. Although recent publications have revealed that there is no significant difference in the incidence of upper airway events between desflurane and sevoflurane during the maintenance of general anaesthesia, results from this meta-analysis indicate that the risk of respiratory events was increased and the time to eye opening was decreased in patients who were administered desflurane compared with those who were administered sevoflurane during ambulatory surgery.9–11 This meta-analysis reveals that, compared with sevoflurane, using desflurane in ambulatory surgery increases the overall risk of respiratory events and decreases the time to eye opening on a large sample pool analysis. However, our results also revealed that there were no differences in emergence agitation, PONV or time to discharge from the operation room between the desflurane and sevoflurane groups.
Stevanovic et al.11 and De Oliveira et al.9 also conducted meta-analyses on this topic. In their respective studies, Stevanovic et al.11 pooled 13 studies that included 1143 individuals who were administered desflurane or other anaesthetics during general anaesthesia with laryngeal mask. De Oliveira et al.9 pooled seven studies that included 657 individuals who were administered desflurane or sevoflurane during general anaesthesia with LMA. In our present study, we pooled 13 studies that included 1267 patients with an emphasis on the differences between desflurane and sevoflurane in ambulatory surgery. Although Stevanovic et al.11 mentioned that the occurrence of airway events was higher in the desflurane group than in the sevoflurane group, these differences were not statistically significant. We evaluated the latest publications in the present meta-analysis, and this resulted in the inclusion of more studies and study subjects than ever before.
Contrary to the findings presented by De Oliveira et al.9 and Stevanovic et al.,11 our meta-analysis revealed that the overall number of respiratory events was higher in the desflurane group than in the sevoflurane group. The incidence of coughing, laryngospasm and cough was significantly higher in the desflurane group of De Oliveira et al.9 On the basis of an asymmetric funnel plot that indicated the possibility of publication bias, De Oliveira et al.9 were unable to demonstrate that the incidence of upper airway adverse events was higher in the desflurane group than in the sevoflurane group. The included trial conducted by De Oliveira et al.25 was the only one that exhibited opposite results with regard to respiratory events (Fig. 4) and had a moderate risk of reporting bias and a high risk of performance bias (Figs. 2 and 3).
In this study, we evaluated the occurrence of respiratory events from induction until extubation. The definition of adverse respiratory events in our study design is more relevant to clinical practice and reminds clinicians that the airway irritation properties of desflurane should not be neglected or underestimated, especially during ambulatory surgery. Clinicians should be aware of the higher risks of peri-anaesthetic airway events in desflurane-based anaesthesia compared with sevoflurane and should also be well prepared to prevent such incidents. The subgroup analysis of the main outcome in the adult and laryngeal mask group revealed similar conclusions; however, there were no significant differences in the paediatric group and endotracheal tube group. The lack of statistical significance in these groups may be explained by the small sample size and paucity of past studies. Premedicating with fentanyl leads to coughing,36 which may interrupt the recording of airway events. In our study, the use of a subgroup analysis clarified these concerns, and the results were consistent in patients who were and who were not premedicated with fentanyl. The testing of subgroup differences according to adults/children, and fentanyl prescription were insignificant, and the result for adverse respiratory events applied to both adults and children, with or without prescribing fentanyl. However, the subgroup analysis according to risk of bias and BIS-guidance were significant. Therefore, our research results are not applicable to these groups.
The PONV rate was not different between the desflurane and sevoflurane groups, including the adults’ and children's groups. Results from a previous study revealed that the incidence of PONV was higher when volatile anaesthetics were used than that when propofol total intravenous anaesthesia was used.37 In recent retrospective studies, the use of desflurane was identified as an independent risk factor for the development of PONV in adults,38 and results from a propensity score matching analysis revealed that the rate of PONV was lower in patients who were administered sevoflurane than those given desflurane during thyroidectomy.39 Our present meta-analysis was not able to adequately respond to the above studies; the prescription of antiemetics in the included trials was not in accordance with recommendations for clinical practice.40 A previous study reported that antiemetic prophylaxis resulted in a significant reduction in the incidence of PONV41; therefore, the use of antiemetics may have influenced the incidence of PONV in the current study. Even though the use of nitrous oxide and prophylactic antiemetics is known to affect the occurrence of PONV, results from the subgroup analyses revealed that the use of prophylactic antiemetics and nitrous oxide had little to no effect on the rate of PONV in our study (data not shown).
Consistent with previously published studies, this meta-analysis also revealed that the time to eye opening was decreased in the desflurane group compared with the sevoflurane group.9,11,42 Rapid recovery from desflurane anaesthesia in both adults and children has been generally acknowledged. We found that the mean difference in the time to eye opening between the desflurane and the sevoflurane group was 3.12 (95% CI, 2.50 to 3.75) min. Although statistically significant, the mean difference was not more than 5 min in present and previous meta-analyses.11,42 According to the analysis of subgroup differences, the results for emergence agitation, PONV, time to eye opening and time to discharge from the operation room are applicable to both adults and children.
Although desflurane is associated with an increased number of adverse respiratory events and decreased time to eye opening, the time between arriving on the PACU to discharge was similar to that in the sevoflurane group; the increased time to eye opening that was associated with sevoflurane did not affect the time spent in the PACU. Oofuvong et al.33 reported that one surgery-related unplanned admission was observed in the sevoflurane group and three surgery-related unplanned admissions were observed in the desflurane group. Two anaesthesia-related unplanned admissions were seen in both groups, and one child from the sevoflurane group had a pulmonary aspiration with desaturation that resolved within two days. No permanent or serious adverse events were observed in any of the other participants.
This study had multiple limitations. First, we restricted the study selection to English language journals, and this may have been a potential source of bias that overestimated of the treatment effect. According to Laura McAuley et al.,43 positive results are more frequently published in English-language journal than negative results. Therefore, the omission non-English language studies may have also overestimated the treatment effect. Second, many factors that may influence the potential ventilatory side effects of desflurane, such as the use of BIS monitoring,44,45 and multimodal analgesia, were not investigated in our study. Third, publication bias was observed in the primary outcome and some of the secondary outcomes, including emergence agitation and time to eye opening, and some biases, such as drugs used for induction, the use of NSAIDs, lidocaine, alpha-2 agonists and muscle relaxants, and the age of children were not evaluated.46 Fourth, results from the time to eye opening and discharge were limited by significant heterogeneity; therefore, these results may be less reliable than originally expected.47 Fifth, this study compared desflurane and sevoflurane in ambulatory surgery; we did not make any comparisons with isoflurane nor did we assess the use of propofol in different types of surgical procedures. Sixth, there may have been some bias resulting from the fact that the overall respiratory events that occurred between induction and extubation depended on various study designs and definitions, including the fact that the recovery profiles that were used to evaluate the time to discharge from operation room varied according to the study. Seventh, adults and children have different pathophysiological manifestations and different incidence rates of airway events, emergence agitation, and PONV even though a subgroup analysis on each outcome had been performed. Results from this study should be applied to clinical practice with caution, and individual differences, surgical types and the advantages and disadvantages of the different volatile anaesthetics should be taken into consideration before the induction of anaesthesia. Further randomised controlled clinical studies are required to confirm the current findings and devise better treatment plans for patients undergoing ambulatory surgery.
Results from our meta-analysis revealed that the number of adverse respiratory events was increased and the time to eye opening was decreased in patients who were administered desflurane compared with sevoflurane during ambulatory surgery. Despite recently published reports that the incidence rate of adverse respiratory events was not significantly different between desflurane and sevoflurane, we observed statistically significant differences in the incidence of adverse respiratory events between the two anaesthetics. Although desflurane is associated with a fast recovery rate, the occurrence of respiratory events should not be neglected and its airway irritant properties should be taken into account. In the future, anaesthesiologists should consider the advantages and disadvantages of each drug when selecting anaesthetics for ambulatory anaesthesia.
Acknowledgements relating to this article
Assistance with the study: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
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21. Wetterslev J, Thorlund K, Brok J, Gluud C. Trial sequential analysis may establish when firm evidence is reached in cumulative meta-analysis. J Clin Epidemiol
22. Thorlund K, Devereaux PJ, Wetterslev J, et al. Can trial sequential monitoring boundaries reduce spurious inferences from meta-analyses? Int J Epidemiol
23. Kim EH, Song IK, Lee JH, et al. Desflurane versus sevoflurane in pediatric anesthesia with a laryngeal mask airway: a randomized controlled trial. Medicine (Baltimore)
24. Mahmoud NA, Rose DJ, Laurence AS. Desflurane or sevoflurane for gynaecological day-case anaesthesia with spontaneous respiration? Anaesthesia
25. De Oliveira GS Jr, Fitzgerald PC, Ahmad S, et al. Desflurane/fentanyl compared with sevoflurane/fentanyl on awakening and quality of recovery in outpatient surgery using a laryngeal mask airway: a randomized, double-blinded controlled trial. J Clin Anesth
26. Dalal KS, Choudhary MV, Palsania AJ, Toal PV. Desflurane for ambulatory anaesthesia: a comparison with sevoflurane for recovery profile and airway responses. Indian J Anaesth
27. Eshima RW, Maurer A, King T, et al. A comparison of airway responses during desflurane and sevoflurane administration via a laryngeal mask airway for maintenance of anesthesia. Anesth Analg
2003; 96:701–705. table of contents.
28. Saros GB, Doolke A, Anderson RE, Jakobsson JG. Desflurane vs. sevoflurane as the main inhaled anaesthetic for spontaneous breathing via a laryngeal mask for varicose vein day surgery: a prospective randomized study. Acta Anaesthesiol Scand
29. Jadhav SV, Gomes P, Daftary S. Comparison of postoperative recovery from desflurane and sevoflurane anaesthesia using laryngeal mask airway: a prospective randomized comparative study. IJRMS
30. Jindal R, Kumra VP, Narani KK, Sood J. Comparison of maintenance and emergence characteristics after desflurane or sevoflurane in outpatient anaesthesia. Indian J Anaesth
31. Kotwani MB, Malde AD. Comparison of maintenance, emergence and recovery characteristics of sevoflurane and desflurane in pediatric ambulatory surgery. J Anaesthesiol Clin Pharmacol
32. Kurhekar P, Vinod K, Krishna JSD, Raghuraman MS. Randomized comparison of isoflurane versus sevoflurane and desflurane for maintenance of ambulatory anesthesia. Anesth Essays Res
33. Oofuvong M, Siripruekpong S, Naklongdee J, et al. Comparison the incidence of emergence agitation between sevoflurane and desflurane after pediatric ambulatory urologic surgery. J Med Assoc Thai
34. Werner JG, Castellon-Larios K, Thongrong C, et al. Desflurane allows for a faster emergence when compared to sevoflurane without affecting the baseline cognitive recovery time. Front Med (Lausanne)
35. White PF, Tang J, Wender RH, et al. Desflurane versus sevoflurane for maintenance of outpatient anesthesia: the effect on early versus late recovery and perioperative coughing. Anesth Analg
36. Tan W, Li S, Liu X, et al. Prophylactic Intravenous lidocaine at different doses for fentanyl-induced cough (FIC): a meta-analysis. Sci Rep
37. Schraag S, Pradelli L, Alsaleh AJO, et al. Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis. BMC Anesthesiol
38. Yi MS, Kang H, Kim MK, et al. Relationship between the incidence and risk factors of postoperative nausea and vomiting in patients with intravenous patient-controlled analgesia. Asian J Surg
39. Yoon IJ, Kang H, Baek CW, et al. Comparison of effects of desflurane and sevoflurane on postoperative nausea, vomiting, and pain in patients receiving opioid-based intravenous patient-controlled analgesia after thyroidectomy: propensity score matching analysis. Medicine (Baltimore)
40. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg
41. Dewinter G, Staelens W, Veef E, et al. Simplified algorithm for the prevention of postoperative nausea and vomiting: a before-and-after study. Br J Anaesth
42. Lim BG, Lee IO, Ahn H, et al. Comparison of the incidence of emergence agitation and emergence times between desflurane and sevoflurane anesthesia in children: a systematic review and meta-analysis. Medicine (Baltimore)
43. McAuley L, Pham B, Tugwell P, Moher D. Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses? Lancet
44. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev
45. Luginbuhl M, Wüthrich S, Petersen-Felix S, et al. Different benefit of bispectral index (BIS) in desflurane and propofol anesthesia. Acta Anaesthesiol Scand
46. Costi D, Cyna AM, Ahmed S, et al. Effects of sevoflurane versus other general anaesthesia on emergence agitation in children. Cochrane Database Syst Rev
47. Imrey PB. Limitations of meta-analyses of studies with high heterogeneity. JAMA Netw Open


Written by Hans Nicolai Adam, Postdoctoral Researcher, Noragric
Harbouring one of the largest mangrove forest tracks in the world, the Sunderbans cover a sizeable area in southern Bangladesh and east India. Formed by the confluence of three major rivers, the deltaic region which the Sunderbans are part of, is famed for its tiger habitats and dynamic ecology. Researchers from a Norwegian Research Council-funded and Noragric-led project ‘Uncertainty, Climate Change and Transformation’ visited the area in January this year. They explored how the interplay between fluid deltaic ecology, climate change, natural disasters and socio-economic issues pose enormous challenges to human settlements on the densely inhabited islands of the Indian Sunderbans.
Ghoramara island, one of the project’s research sites, represents an extreme case. An impoverished island close to the Bay of Bengal, it has suffered from governmental neglect and is largely devoid of basic amenities. It has been scarred by Cyclone Aila in 2009 and offers few livelihood opportunities. Its most striking feature is that it is a ‘sinking island’. Lying below sea level and having its coastline gradually chipped away through erosion, its residents are gradually migrating. Their future, as in other inhabited islands of the Sunderbans, is uncertain and contested. Predictions of impeding catastrophe co-exist with narratives of persistence, creativity and survival.
As the world braces for the impacts of climate change and international actors grapple to find political solutions on the mitigation and adaptation front, the case of Ghoramara represents a microcosm of the kind of complex and interacting issues that extremely vulnerable population sections in the global south already face now, and more so in the future: Local and global environmental change, development neglect, poor policy and institutional design. Contrary to the popular imagery of impending disaster, project researchers also acknowledge and try to understand how local people – in many cases successfully – adapt and transform in challenging circumstances.
How do its people deal with uncertainty related to climate change? Models, projections and scenarios form a key part of established climate change science and understanding uncertainty, but tend to underplay its human and social dimensions. Local people experience climate extremes, its uncertainty and consequences on a day-to-day basis in ways that abstract models are not able to capture. This is where the project seeks to contribute and inform research as well as well policy. Project leader Lyla Mehta (Institute of Development Studies, UK / Noragric) puts it as follows:
Uncertainty is usually conceptualized from ‘above’ by experts and scientists in quantifiable ways. But these understandings ignore lived experiences of uncertainty – what we call uncertainty from ‘below.’ There is also the ‘middle’ – the knowledge brokers and interlocutors who seek to communicate between the two. It is in the middle wherein we, as a project, see ourselves placed.
Apart from the Sunderbans, similar questions are examined in different contexts. These include a megalopolis in India, Mumbai and a dryland area in the west of India, Kutch.
At the end of January, a workshop in New Delhi organized by the STEPS centre on ‘Climate change and uncertainty from above and below’ invited key academic figures, policy makers and civil society actors to deliberate issues that revolve around understanding and dealing with uncertainty. These involved the presentation of empirical research findings from India, Africa and beyond, aside from discussing epistemological and conceptual questions. All of these contributed to rich discussions which will be reported in future blogs and included in a planned special journal issue.


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Panji, Goa: Rahul Gandhi, a Congress leader and MP, arrived in Goa for a one-day visit during which the party’s candidates will take a vow of allegiance in his presence. After the polls, the candidates will swear not to defect. The Congress won 17 of the 40 seats in Goa in 2017, while the BJP won 13.
Read also- Need to get out from thinking ‘Indira is India & India is Indira’: Naqvi slams Rahul Gandhi
However, 15 Congress MLAs defected to the BJP in 2019, led by Babu Kavlekar, the Congress’s leader of opposition, who was appointed Deputy Chief Minister by the BJP.
However, the loyalty pledge started by the Aam Aadmi Party (AAP) to sign anti-defection affidavits. Unlike, AAP Congress is following the same process.
Rahul Gandhi was supposed to visit on February 2, however his trip was postponed due to parliament and a trip to Raipur to inaugurate a martyrs’ memorial.
Read also- Rahul Gandhi to be first speaker in debate on Motion of Thanks
Rahul Gandhi will also meet with tourism industry officials, Anganwadi workers, and others. Later today, he will have a door-to-door campaign in Sada, Mormugao, and meet with candidates.

domain: news


text:
Spider-Man is possibly the most recognisable superheroes of all time – the distinctive wide eyes and the web pattern on the costume give him a very unique appearance, but have you ever thought about what’s on the inside?
If you hadn’t, don’t worry, neither had I, BUT Marvel Studios’ Head of Visual Development Ryan Meinerding has shared a look inside the mask from the Spider-Man: Homecoming suit – i.e. the suit Tony Stark designed for Peter Parker.
Meinerding wrote, “This is the Homecoming mask turned inside out—I did this design for the scene where Peter and Ned hack the suit. It wasn’t really shown, but I used it for the damaged version of the suit I posted earlier.”
The inside of the suit was going to be seen when it got damaged later in Spider-Man: Homecoming, that version he’s referring to is this one:
So, now we know the inside of the mask looks so much crazier than the outside.
Considering the suit was from Stark and featured a lot of technology, it’s unsurprising really that the suit would have a lot of circuitry inside.
It would make sense if the new suit Peter makes in Spider-Man: Far From Home had a similar look because it was so packed with technology as well.
While we won’t see another Spidey movie for a couple of years, it’s cool to know the level of detail the filmmakers go into when creating these characters and their costumes.
Earlier this year we saw a photo of Tom Holland drinking a coffee while in the Spider-Man suit, and it turns out the easiest way to do that is by taking out one of the eyepieces and go through the eye hole with a straw!
It honestly looks like he’s crying coffee… very weird!

domain: artistic


Rudyard Rallies Late, USA Early, to Set Up Title Clash
By Keith Dunlap
Special for MHSAA.com
June 18, 2021
EAST LANSING – Before Rudyard senior Morgan Bickel stepped to the plate with one out in the bottom of the ninth inning of a tied Semifinal against Holton on Friday, she got some advice from her coaches in the dugout that seemed a bit perplexing.
“My coaches were like, ‘Just hit a home run and we win,’” said Bickel, who entered that at-bat with just two home runs on the year. “I just kind of laughed it off. I was just looking for solid contact. Something off of the barrel.”
Seconds later, Bickel indeed made contact off of the barrel and went from laughing off the advice of her coaches to walking it off for Rudyard, blasting the game-winning home run over the fence in right to give Rudyard a stunning 9-8 win.
Holton held a 7-1 lead with two outs in the fifth and before the Bulldogs improbably rallied to advance to their first Final on Saturday.
“We haven’t been down 7-1 and come back (this year), but we know we are a team that can score runs,” Rudyard head coach Stephen Davis said. “We never once panicked.”
Rudyard (28-5) started its rally in the fifth inning when No. 7 hitter Tori Tremblay and No. 9 hitter Chesney Molina each walked to set the stage for leadoff hitter Paige Postma, who injected some life into her team by hitting a three-run home run with two outs to left-center to cut Holton’s lead to 7-4.
Each team scored a run in the sixth inning, and then Rudyard scored three runs with two outs in the bottom of the seventh to tie the game at 8-8.
Molina walked to start the inning to turn the lineup over, and then with two outs, Bickel and Meagan Postma each hit RBI singles to cut Holton’s lead to 8-7.
Karlee Mayer then hit an RBI double to right-center just out of the reach of Holton’s diving right fielder to tie the game at 8-8.
In the top of the eighth, Holton loaded the bases with one out, but Bickel got out of the jam with a groundout and subsequent force at home, and then a strikeout.
After a scoreless eighth, Bickel retired Holton in order in the top of the ninth to set up her heroics.
“It was just funny at that moment that the coaches said to hit a home run, and I ended up doing it,” Bickel said.
Holton (35-7) seemed to be in cruise control after building a 7-1 lead, scoring a single run in the first, four runs in the second and single runs in the third and fourth.
But ultimately, some untimely walks and not producing enough offense in the late innings proved too costly.
Abigail Fowler and Madison Bosset each went 3-for-5, Gianna Reed went 2-for-2 with two runs scored and an RBI and Ryann Robins had three RBI to lead Holton.
“Hats off to them,” Holton head coach Kirk Younts said. “They hit the ball. It was a tight game, and they are a good team. They battled, and so did we. We had some chances to score, and we didn’t.”
Unionville-Sebewaing 9, Bridgman 2
Reigning champion Unionville-Sebewaing left no doubt from the beginning, jumping out to a 4-0 lead during the first inning and adding three more runs in the second to take a 7-0 lead en route to a 9-2 win.
USA advanced to meet Rudyard in what will be the fourth Finals appearance for the Patriots since 2015.
“Putting four in the first inning kind of allows the girls to relax a little bit and slow the game down,” USA head coach Isaiah Gainforth said. “Coming back in the second inning and getting three maybe was even bigger.”
Laci Harris went 4-for-4 with two RBI and three runs and Gabriella Crumm went 3-for-3 with four RBI to lead a 10-hit attack for USA.
The offense was more than enough for USA starter Brynn Polega, who struck out 10 and didn’t give up an earned run in tossing a three-hitter.
Hannah Johnson had the lone RBI for Bridgman (39-3), which made its first appearance in the Semifinals.
“They knew what to expect,” Bridgman head coach Elaine Starbuck said of USA’s experience playing in later rounds of the playoffs. “Nerves I’m sure got the best of us. We gave up a few passed balls that allowed them to score, and their hitters are solid.”
PHOTOS: (Top) Rudyard’s Chesney Molina (12) slides safely into second base during her team’s victory Friday at Secchia Stadium. (Middle) Unionville-Sebewaing’s Macy Reinhardt (5) keeps her eyes on a drive during her team’s Semifinal win.
Owosso Ace's Strikeout Total Stacks Up with State's All-Time Best
By Geoff Kimmerly
MHSAA.com senior editor
January 4, 2023
Owosso’s Macy Irelan earned 11 entries in the MHSAA record book over her three-year varsity career that came to a close last spring, most notably with her 1,157 strikeouts despite the 2020 season being canceled due to COVID-19.
Irelan’s career strikeouts were the second-most in the state since the pitching distance was lengthened three feet in 2011. She finished 31-7 last spring with a 1.43 ERA and 414 strikeouts in 229 2/3 innings in earning the Miss Softball Award for pitching.
She also hit .551 with 21 doubles last season, and her 55 career doubles over 117 games and three seasons made that category career list. She’s continuing her career at Kent State.
See below for more recent additions to the softball record book:
Unionville-Sebewaing’s dominating run to the 2021 Division 4 championship was filled with seven record book-worthy highlights, including many near the top of all-time lists. In going 40-3, the Patriots tied their season record for wins for the second time. Their 502 runs scored ranked third all-time, with their 493 hits tied for ninth, their 114 doubles second, their 49 home runs also tied for ninth, their 431 RBI also second and their 503 strikeouts thrown ranking third. Senior Brynn Polega completed her career with 13 record book entries despite her junior season being canceled because of COVID-19; she added listings for 71 runs, 79 hits, a third-best 28 doubles, 11 homers, 70 RBI, four perfect games pitching and 365 strikeouts, among others. Then-junior Laci Harris made lists with 77 runs, 83 hits, 22 doubles, 14 homers and 78 RBI, while then-junior Macy Reinhardt was added for 78 runs and then-freshman Gabriella Crumm was added for 16 doubles. Polega, Harris and Reinhardt also posted entries for single-game accomplishments. Polega is playing at Northwood and Harris at Madonna.
Big Rapids set a school record for wins in 2021 in finishing 34-7, a run which included a number of accomplishments that reached the record book. The Cardinals scored 439 runs – tied for 12th on that list – and also as a team were added for 428 hits, 82 doubles and 363 RBI, which tied for 10th all-time. Marissa Warren made the individual hits list with 71, while Hanna Smith earned an entry with 20 doubles and Rylie Haist followed with 19. Josie Cornell was added with 40 walks drawn. Warren, Smith and Haist were added for single-game accomplishments as well, as was Madison Affer from a 2019 game. Haist, Smith and Cornell are seniors this school year, and Warren is a junior. Smith has signed with Ferris State.
A pair of Bad Axe standouts earned record book entries in 2021 with their work at the plate. Haley Newland made the single-season doubles list with 19, and Brooke Messing was added for seven RBI in a game that saw her hit a grand slam and three-run homer. Newland graduated last spring and Messing is a senior this school year.
Montrose then-freshman Lainey Cannon made two record book lists with her performance April 25 against Montrose. She hit three home runs to make the single-game list in that category, and also made the single-game RBI list with eight.
Capac then-sophomore Madalyn Roberson made the record book three times with her performance May 9 against Brown City. She hit two home runs in back-to-back at bats, both during the fifth inning, and also drove in six runs for the game.
Spring Lake standouts now fill the record book after the addition of 55 individual and 23 team entries dating back to the 2000 season. Among listings ranking highest in their respective categories were Madelyn Nelson’s 81 runs in 2018, which tied for seventh all-time; Nelson’s 250 career runs from 2015-18) that rank seventh and Lauren Hellman’s 249 career runs also from 2015-18 that rank eighth on that list; Nelson’s 84 hits in 2018 that are tied for 12th-most all-time and her 264 career hits that rank 11th, Leah Vaughan’s 26 doubles in 2019 that rank seventh, Evie Lorimer’s 16 triples in 2011 that are tied for eighth and her 37 career triples from 2010-12 that are ranked fourth, Vaughan’s 23 career times being hit by pitch from 2016-19 which rank second, and Lorimer’s 92 stolen bases in 2012 that rank second (with all 92 coming consecutively to tie for fifth on that list) and 183 career steals that rank 11th. As a team, Spring Lake in 2017 ranked seventh all-time with 501 hits over 42 games, fourth with 109 doubles and eighth with 34 triples. The 2018 team ranks 11th with 441 runs scored over 41 games, 10th with 497 hits and tied for ninth with 100 doubles. Valerie Alter, Linsey Paggeot, Jenna Core, Molly Poole, Alicia Mumby, Leah Anton, Ann Marie Galloway and Rachael Adams also earned individual entries. Nelson went on to play at Grand Valley State, Vaughan plays at Aquinas College, Lorimer played at Central Michigan, Alter played at Jacksonville University (Fla.), Poole plays at Cornerstone University and Mumby played at Lansing Community College. Core plays volleyball at Hope College.
Freeland’s offense earned five record book entries during the team’s 26-12 season in 2022, including for 412 runs scored, 442 hits, 78 doubles, 336 RBI and a .400 team batting average. Three individuals also earned entries – sophomore Addie Steffen for a 20-game hitting streak and seven RBI in a game, junior Evelynn Rybicki for six RBI in a game and freshman Brynn Jaime for getting hit by a pitch twice in the same inning.
Chloe Parker hit .604 last spring and made the records with 20 doubles over 33 games for Niles Brandywine. She’s a junior this school year.
A series of record book entries were added for past and present Zeeland West standouts. Carly Sleeman was added for 73 runs, 75 hits, 27 doubles and 12 home runs in 2021 as a sophomore, while Lily Brower was added for 72 runs, 17 triples and 11 homers, plus 38 doubles and 29 triples over a four-year varsity career. Sleeman’s 27 doubles are tied for fifth-most in one season, and Brower’s 17 triples are tied for fourth on that list. Haley Hoogenraad was added for 70 hits and 17 doubles as a junior in 2015, 19 doubles as a senior, and 49 doubles and 24 triples over her four-year career from 2013-16. Kenzie Siersma was added for 17 doubles in 2017 and 54 over her career from 2016-19, while Courtney Sleeman made the season home runs list with 15 in 2015 and Sarah VanValkenburg made the career RBI list with 152 from 2014-17. Emily Brands was added for hitting consecutive home runs in the same inning, May 7 against Reese; she graduated this spring. Hoogenraad went on to play at University of Michigan, Courtney Sleeman played at Western Michigan, Siersma plays at West Virginia Tech, Brower played last season at Kalamazoo Valley Community College, and Carly Sleeman has signed with Central Michigan.
PHOTO Owosso’s Macy Irelan unloads a pitch during the 2021 Division 2 Final.


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New Earth/Systir Series
Genre: Fiction, Sci-Fi
Number of Books: 2 books – Original and its Sequel
Synopsis: Systir is a planet that was inhabited after humans had to abandon earth due to a cataclysmic event. It affectionately became known as New Earth, in memory of the foregone home of the human race. Gathering people and finding a way to have many nations collaborate to help save the race was an enormous feat. Now, a few hundred years after the foundation of the new territories and their governments, factions are beginning to form, causing a deep rift socially and economically among the territories. Little known to many people, one faction, irritated by the current political situation and seeking to gain control, is taking a chance by chasing after a myth. Only a few who are descendants of the top politicians and scientists who brought humans to Systir know the truth, and while one seeks to gain an advantage with it, another is attempting to rid of the myth once and for all. This story follows a boy who is caught in the middle of the publicly undisclosed terror when he accidentally discovers a disk containing valuable information.

domain: literature


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|Officials from Cheong Wa Dae, the government and the ruling Democratic Party of Korea (DPK) hold a meeting at the National Assembly in Seoul, Tuesday, to discuss the introduction of free education for high school students. /Yonhap|
By Bahk Eun-ji
All high school students in Korea will get a free education starting 2021, the government said, Tuesday.
Cheong Wa Dae, the ruling Democratic Party of Korea (DPK) and the relevant ministries agreed on providing the long-awaited free education gradually to all high school students, after a meeting at the National Assembly, Tuesday, according to the Ministry of Education
So far Korea has only offered free education at elementary and middle school levels, which are compulsory.
Free tuition at high schools has been one of the top education policy goals of the Moon Jae-in administration.
According to the ministry, free high school education will begin for seniors in the second semester of this year and will be expanded gradually to sophomores next year and juniors by 2021.
All expenses for high school education, such as admission fees, school operation fees, tuition and textbook purchases, will be covered. But students who attend special-purpose elite schools or autonomous private high schools, which do not receive financial aid from regional education offices, will be excluded.
"The right to be educated is one of the basic rights stipulated in the Constitution, and it is an indispensable task to realize such a basic right," DPK floor leader Hong Young-pyo said at the beginning of the meeting. "Among 35 OECD countries, Korea is the only country where high school students do not get a free education."
Vice Finance Minister Koo Yoon-cheol also said the free education would help a household with one high school student save 1.58 million won ($1,382) per year.
The central government and regional education offices will share the cost of providing the free education, estimated to be about an annual 2 trillion won, with each paying 50 percent.
Hong said the ruling party would make efforts to have relevant revisions passed by the National Assembly during the first half of the year to enable the free education for seniors to start in the latter half.
Education Minister Yoo Eun-hae said this free education provision is expected to help parents reduce education costs, especially for families that have been excluded from government subsidies for high school tuition because they make marginally too much to qualify for the subsidy.
"The central government and education offices will cooperate closely to implement the long-awaited free education for high school students," Yoo said.
She added that free education does not mean high school attendance will become compulsory. "I don't see the need to make it compulsory as almost 100 percent of middle school students already go on to high school," she said.
Teachers' groups and education-related organizations generally welcomed the decision, but showed concern over whether regional education offices will be able to afford their portion of the cost.


Smart gird, integrated power network with communication network, has brought an innovation of traditional power for future green energy. Optical fiber technology and synchronous digital hierarchy (SDH) technology is widely used in smart grid communication transmission network. It is a challenge to reduce impact of the availability of smart grid communication services caused by random failures and random time to repair. Firstly, we create a service channel violation risk degree (SCVRD
) model to precisely track the violation risk change of communication service channel. It is denoted by the probability of service channel cumulative failure duration exceeding the prescribed duration. Secondly, a service channel violation risk degree routing mechanism is proposed to improve the availability of communication service. At last, the simulation is implemented with MATLAB and network data in one province are used as data instance. The simulation results show that the average service channel failure rate of availability-aware routing based on statistics (AAR-OS) algorithm and risk-aware provisioning algorithm are reduced by 15% and 6%, respectively.
This is an open access article distributed under the Creative Commons Attribution License
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited


text:
Play Free Mobile Games on 2FlashGames.Com
Play most popular mobile games, anytime, anywhere on your mobile devices
Are you well-padded and want to lose a few pounds? Get Fit turns working out and getting in shape into fun and entertaining mini games. In each of the mini games you accompany a character on it’s way from being chubby to a real beefcake. You can test your reaction in sports like rope skipping, lifting and the famous hula hoop. The longer you play the fitter your character gets. Just like in real life getting fit is easier as staying fit. If you start to slack off and skip your training for some days your character will gain weight again. So make sure to come back every day and work out! Play Get Fit now for free!
Language: deutsch, english, français, italiano, Nederlands, polski, português, Русский язык, español, Türkçe, 中文
Rating: 3 out of 5
Become the ultimate royal knight in this dynamic and challenging strategy game. Your objective is to conquer all enemy strongholds. Move your armies through the battlefield and buy upgrades to improve the skills of your soldiers. Will you be able to successfully battle through all levels?
Road Safety is not only a fast paced frogger style action game but it also lots and lots of fun! The player helps people to cross roads without being injured by cars. To pass a level a given number of people needs to reach the exit unharmed saved.A single tap or swipe makes the people move forward. You can’t really check the traffic forever and wait for the perfect moment as time is limited and you need to hurry up! Play Road Safety now for free and escort all the kids to safety. You wouldn’t want them to find and an cruel and untimely end in front of a car, right? RIGHT?!
Skill, Arcade Games
Be a real Treasure Miner in this free online game and pull all sorts of riches out of the soil - you'll dig it! While other miners drive tunnels into the mountains you mine the cool way! You just ram your hook into the ground and pull up whatever ores or gem you are able to grab within sixty seconds. To help you maximize your profit you can invest the points you've earned in helpful tools like a better hook, bombs to blow up the useless rocks in your way, some extra time or the ability to pull your hook back faster. Play now see if you can be one of the few miners who actually get rich!
Puzzle Games, Skill

domain: entertainment


text:
Human Statue / Live Statues (Egyptian)
We have a variety of Human Statues for all kinds of events. They are a unique entertainment that can be placed at the entrance or welcome area of the event.
3 sets of 10 minutes
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Description Let your guests take an arabic souvenir at your next event with our talented arabic calligrapher making live art for their names.
Description Transform your event entrance with our glamorous living red carpet. Give guests a VIP feeling and something to talk about the moment they arrive!…
Description Lookalikes are the perfect addition to any event, be it the Villains from 007, to iconic singers or actors. Duration 1 set by 5…
Description Group of stilt walkers performing as marching band, costumes and musical instruments are included. Duration 3 sets of 15 minutes


text:
Doctors at Brigham and Women's Hospital say they don't know when Boston Mayor Thomas Menino will be released from the hospital, where he's been in treatment for nearly three weeks.
Menino's attending physician, Dr. Charles Morris, says the mayor arrived with a viral infection and a blood clot in his leg when he checked in on Oct. 26.
"When he got here, he was weak and very washed out," Morris said. "We had to do work on a number of fronts, fortunately he responded on all of those."
Doctors say although Menino has recovered from the infection, he is still in pain from a compression fracture in his back that has become more painful over the last couple of days. Doctors do not know the cause of the fracture.
Because of the back problems, doctors won't say when the mayor will be going home.
Menino's office says the mayor is conducting city business from his hospital bed.
This program aired on November 13, 2012. The audio for this program is not available.

domain: health


text:
Black, Yellow Recycled Sterling Silver
D for Diamond Children's Silver & Gold Plated Diamond Bee Expandable Bangle B5369 nj10081ss0
filter_vintage FREE DELIVERY on orders over £50
This beautiful bee bangle by D for Diamond is the perfect keepsake for a little one. The expandable bangle is crafted from recycled sterling silver, and features striking stripes of black enamel and yellow gold plating, with a sparkling diamond accent in the wing of the bee for an extra special touch. This bangle can be engraved with a special message of your choice, making this a meaningful gift that can be cherished forever.
- Made from Recycled Sterling Silver
- Platinum Plated and Gold Plated
- Diamond and Enamel
- Diameter approx 45-52mm, Width 4mm, Bee size 7mm x 9mm
- Presented in official D for Diamond packaging
About D for Diamond
D for Diamond
Celebrate your child's precious moments with D for Diamond's range of adorable children's jewellery and keepsakes - the perfect gift for your little one.
From expandable bangles embellished with diamonds, to cute watches and pretty pendants, D for Diamond creates sterling silver jewellery for children of all ages, that they can wear every day but cherish forever.


Santa Cruz police are searching for the driver of a pickup truck who drove away after dropping off a stabbing victim at a hospital emergency room Monday, a police spokesman said. The 31-year-old male stabbing victim, who has an extensive history of police contact, underwent surgery Monday at Dominican Hospital, Deputy Police Chief Steve Clark said. At 3:55 p.m. Monday, police were dispatched to the area of San Lorenzo Boulevard and Riverside Avenue after an off-duty firefighter reported seeing an injured person being placed into a vehicle, Clark said.
Police soon received a call from the emergency medical staff at Dominican Hospital about a stabbing victim dropped off by the driver of a mid-2000s Dodge Quad Cab pickup truck, Clark said. Detectives are looking for that truck and a second truck, described as a small Ford sport utility vehicle, Clark said. The motive and circumstances of the stabbing are still being investigated, Clark said.
Please call the Fugitive Watch hot line at 1-800-9-CAUGHT (1-800-922-8448) or text us at 408-355-0999 or CLICK HERE to send a confidential email tip, if you know the name of this suspect or have any information that can help solve this crime
Por favor llame la línea de Los Fugitivos en 1-800-9-CAUGHT (1-800-922-8448) o texto en 408-355-0999 o haga clic aquí para envia un email a [email protected], si usted tiene alguna información que pueda ayudar a resolver este crimen.
Copyright © 2013 by Bay City News, Inc. — Republication, Rebroadcast or any other Reuse without the express written consent of Bay City News, Inc. is prohibited.


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G-Force is a team of highly trained guinea pigs that are able to accomplish many missions that humans are unable to. The F.B.I. doesn’t see their potential though and shuts down the project right when they were in the middle of uncovering a devious plan. The guinea Darwin, Blaster, and Juarez are taken to a pet shop; but they won’t let this setback stop them from saving the world. Working with some new friends they will uncover the mastermind trying to wipe out the world and prove themselves as worthy agents.
Mixing CGI with live action “G-Force” gives you adorable guinea pigs, explosive action, and family fun. The story is simple but fun for kids. The voice actors especially Tracy Morgan will help make the movie not just watchable but amusing for adults. Perhaps not the best movie to come from Disney recently but an amusing one to add to the collection.
Unfortunately it does not seem like they are releasing this just on Blu-Ray, meaning that you either have to buy it on DVD or in the more expensive combo pack.
The picture quality is great as is the sound for the Blu-Ray disc.
Blaster’s Boot Camp – Quick run-through of some of the gadgets used in the movie
G-Force Mastermind – Talking to the director & his son who came up with the idea for the movie and how the movie came to be.
Music Videos – Flo Rida’s “Jump”, Steve Rushton’s “Ready To Rock”, & “Go G-Force”


In an effort to continue to keep you posted on the Housing Development being proposed off Bickley Road, I checked with SC State Housing today. Below is their response:
We have completed the application reviews and notified developers of missing/incomplete documents giving them a seven (7) day business day timeframe to provide the missing/incomplete documents. Point scoring will begin this week and we hope to finish by the end of next week. A double check of the initial scores will be done before posting preliminary point scores to the tax credit webpage. We anticipate posting scores around the second week of May.
The underwriting analysis and reviews are just beginning. Depending on the time it takes to complete these we anticipate making award announcements by the end of June.
We have received 188 letters and one (1) petition containing 106 signatures in opposition to the development. We have not received any positive support letters. As for phone calls, I have not kept a record of those but would estimate having received around 10 calls from neighborhood residents.
Should you need anything further or have additional questions please feel free to call me.
SC State Housing Finance & Development Authority


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Whole Goose Foie Gras
Deliveries are made on Wednesday, Thursday and Friday
Easy and secure payment by credit card or PayPal
Delivery in over 15 countries
Freshly packed and protected
1 year at a temperature of 0°C to + 4°C
goose liver, salt, sugar, spices, antioxidant : sodium ascorbate, preservative : sodium nitrite.
Energy 1962 kJ / 476 kcal, Fat 48g of which saturates 18g , Carbohydrate 2,3g of which sugars 1,6g, Protein 8,3g, Salt 1,4g
2 in 1 use: a Foie Gras to be eaten hot or cold
Here is a product that will delight both purists thanks to its original form of Foie and also those looking for originality with the possibility of eating it hot, in the pan-fried Foie Gras version.
In order to guarantee a lobe of Foie Gras with a minimum of melting during cooking, this product is pre-cooked in a bag at low temperature.
You can eat it as is, on toast, or cut it into 8 to 10 beautiful escalopes. You will thus obtain pan-fried Foie Gras escalopes that are easy to prepare without any special handling or technique.
An easy to prepare product, ideal as a starter for 5 people or as a main course for 3 guests.
The Edouard Artzner House, a unique know-how
This lobe of Goose Foie Gras has been carefully prepared by our Chefs according to a unique recipe preserved since 1803.
In order to guarantee exceptional quality, your Foie Gras has been cold deveined. This is an artisanal process which allows the extraction of all the veins. It is therefore free of all imperfections.
It is then seasoned with a subtle blend of 13 spices (salt, pepper, etc.), which will give your Foie Gras a bouquet of fine and light aromas.
After being seasoned, your lobe of Goose Foie Gras is cooked at a low temperature to obtain a smooth and melting texture.
Realize a mythical dish of French cuisine: tournedos Rossini
made with cooked beef fillet placed on bread, covered with a slice of pan-fried Foie Gras and drizzled with a truffle and Madeira sauce.
Frequently Asked Questions
To cook the Goose Foie Gras escalopes successfully, cut your lobe into slices about 1.5 cm thick. Once your slices are cut, place your Goose Foie Gras escalopes directly into a hot frying pan, without adding any fat. Sear your cutlets for about 1.5 minutes on each side.
Caution: Pan-fried Foie Gras cools quickly and should be served quickly after cooking.
If you are looking for an original recipe, discover without further delay our Pan-Fried Foie Gras with pumpkin cream, made by our Chef.
To sublimate your pan-fried Foie Gras you can combine it with sweet flavours, such as a compote of apples, figs or apricots.
Fresh Foie Gras is cooked at a slightly lower temperature than semi-preserved Foie Gras. The texture is therefore different: smooth and melting for fresh Foie Gras and a little firmer for semi-cooked Foie Gras. The latter has an undeniable advantage: it keeps longer (1 year in the refrigerator). So you will never be caught unprepared if you have surprise guests.

domain: food


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myBonzle menu: Add to my places Add picture Add story Add note
Skip to map
Spencer Gulf is off the east coast of South Australia. Spencer Gulf is in the Southern Ocean.
The three nearest beaches to Spencer Gulf are Eight Mile Creek Beach, Murrippi Beach and Murninnie Beach.
The nearest road to Spencer Gulf is an unsealed road that is un-named in our database (6.56km away).
The nearest sealed road to Spencer Gulf is the Princes Highway (10.6km away).
Have you caught or seen fish at Spencer Gulf? Contribute your knowledge by clicking here.
Do you know what facilities are available at Spencer Gulf? Contribute your knowledge by clicking here.
Bonzle users have reported that Spencer Gulf is a good place for jet skiing. Do you know of other recreational activities at Spencer Gulf? Is this list accurate? Contribute your knowledge by clicking here.
If you're interested in Bays then you may also be interested in Reefs and Fishing Spots, Waveriders, Wrecks, Fish Attracting Devices, Artificial Reefs, Channels and Passages, Beaches, Capes and Seamounts.

domain: geography


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Back in 1976, brother Dr. Herb Dedo ’52 started taking his young son to Cal football games. When he stopped by the chapter house, he was surprised to learn that years before, back in the days of Mario Savio and the Berkeley Free Speech Movement, SAE Cal Beta had been reduced to fewer than 10 actives and had been forced to sell the house to Professor Judson Landis who taught Home Economics 113 at Cal.
The sales contract gave Cal Beta the right to rent the house and to have the first right of refusal should it be sold. Professor Landis put the house on the market in late-1976 and filed papers with the court to evict the actives and attempt to repossess the house.
Brother Dedo learned about this, and immediately decided that Cal Beta should attempt to buy back the chapter house which would require substantial funds from the alumni. He first contacted Mike Friedenbach ’50 and the two of them agreed to contribute $10,000 each towards the re-purchase. Brother Dedo then called Bill MacLaughlin ’49 who along with Al Bender ’51 and Ed Lippstreu ’49 also agreed to contribute an additional $10,000 each. Brother Dedo then recruited Jim Riewerts ’51, Bob Conn ’43 and J.C. Armstrong ’39 who combined to pledge another $10,000.
The Cal Beta Investor group then hired an attorney who went to court to fight the repossession and to have the property appraised. The third-party appraisal came in at approximately $500,000. Professor Landis brought in a “straw man” who indicated he would pay an amount in excess of $500,000 for the property. The Investors’ attorney questioned the legitimacy of the straw man in court in front of the judge. It was subsequently determined that the straw man was the manager of one of Professor Landis’ apartment houses and had no money to buy the property. This very much displeased the judge and he gave the Cal Beta Investor group 30 days to come up with the funds to buy the property. In addition, the judge reduced the sale price of the house in consideration of all the work that had been done by the chapter since Professor Landis had acquired the property.
The Cal Beta Investors agreed to guarantee a $240,000, 20-year mortgage from Sacramento Savings & Loan arranged by Bill MacLaughlin. But this amount plus the equity from the Investors still didn’t cover the entire amount necessary to purchase the house. Brother Dedo started calling all the Cal Beta alums he knew requesting contributions. He recalls that he ran up over $900 in phone bills. (Remember this was before the Internet). He received the final $3,600 just hours before the deadline.
Closing escrow was fairly complicated as Professor Landis required that the transaction be handled as an exchange for a property in Sacramento that could be inherited by his son who was a professor at Sacramento State University. After numerous meetings with Professor Landis and his son, Bill MacLaughlin was able to find a medical building that was acceptable and escrow was closed. The Cal Beta Investors now owned the land and building at 2722 Bancroft Way.
Many complicated hours and trips to the Bay Area were involved with this transaction and none of the Investors were reimbursed for their time or out of pocket expenses. All of them performed above and beyond the call of duty — all for the sake of their love of SAE Cal Beta. A lease was written between the Investors and the Cal Beta Chapter and the monthly rent was equal to the mortgage payments plus a reserve for property taxes and insurance. No profits were made by any of the Investors in this transaction.
In the late 1980s and early 1990s the Cal Beta House Corporation set up a non-profit corporation — Cal Beta SAE Educational Institute, Inc. Brother Phil Knox ’41 of the House Corporation then negotiated with the Investors to acquire their ownership of the chapter house. Brothers Dedo and Friedenbach donated their interest to the Institute and the other investors were reimbursed for their original equity contributions. A new mortgage was obtained by the Institute which retired the Sacramento Savings & Loan mortgage that the Investors had personally guaranteed.
Cal Beta is very fortunate that the above named Investors came to our rescue during this crisis. Had they not acted when they did, it is very probable that 2722 Bancroft Way would be owned today by the University or another private investor group and SAE Cal Beta would have been forced to find another home.
We are delighted to induct each of the Cal Beta Investors of the 70s into the Cal Beta Sigma Alpha Epsilon Andy Smith Hall of Fame.

domain: law


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Wakesurfing is an extremely fascinating sports activity that everybody can practice there are actually no constraints, which is comparable to exploring, however, you don’t must paddle. It is now acknowledged on several shorelines, the start is to use a rope plus a wakeboard Geneve, but when you are stable, you surfing the influx freely.
Undoubtedly, an original expertise, simply being dragged with a vessel and then you must release the rope, you can’t skip it, the adrenaline goes up and a lot more with the sound of the sea, undoubtedly the right blend.
All water sports need lots of agility and equilibrium with a wakeboard geneve, you have to do maneuvers. However, to handle this sort of sports activity, you may use two methods: one right from the program, and also the rope is released once the fishing boat has reached the necessary speed.
Along with the other option is straight from the liquid, where you stand dragged using the table where you need to assistance yourself along with your heels. Once you begin the fishing boat, the water can certainly make the table adhere to your toes, and it will be possible to allow go step by step. You will enjoy direct sunlight, the yellow sand, along with a various day time remember that it is a sport tailored for anyone, another approach to discharge stress.
Wakesurf Exercise Recommendations
There are Wakesurf educational institutions that test out first-timers for fifteen minutes of adventure the initial thing they teach them is always to feel the discomfort for being on top of wakeboard Genève. For those who already have encounter, they are able to visit enjoy the sea, also for individuals who would like to rest.
Additionally, these colleges have a boat that sails with 3 pilots or 5 maximum, however if the students want a far more exclusive course, they could enjoy one hour or more and even board 11 individuals. And don’t be concerned about the wetsuits they have got all of the items you will need, the wetsuit, the table, and the finest fitness instructor in the region.
This sport activity has been utilized considering that 1950 in the beginning, unnatural surf were created, an incredibly bold sports activity should you be excited to get in an institution and understand, you can place on your earphones and thus chill out using the surf plus your wakeboard Geneve, what exactly are you awaiting? Will not skip the chance to experience this experience. Hold your space with the closest beachfront and exercise this fantastic h2o sports activity.

domain: hobby


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I'm struggling to get iOptron driver to recognize GPS source attached to my mount.
I've attached screen shots of Options and Mount Info panes of the INDI control panel for the (connected) mount. The GPS dongle had signal and the driver seems to recognize this "Data OK," but it still wouldn't correctly set either the location or the time. I was able to do it manually, but this is frustrating.
Perhaps I'm supposed to enter something clever in the "GPS" box on the "Options" tab, but I don't know what that is! I've tried typing Mount, and GPS, and Dongle but I don't know what INDI wants in there.
In summer I image at a remote mountain sites without main power or any kind of internet, so when I have trouble it's hard to research why!
IIRC, you need to set in your handset that the GPS is the Time Source and it would be reflected in the driver. So Ekos does not see GPS separately, but the time/location coming from the mount as GPS ones. Select "Mount update KStars" and you should be good.
I don 't know about the CEM40 but the GEM45 can be connected to a computer with a USB cable without the need to connect the hand controller. For the latest KStars/Ekos/INDI we needed to update the firmware of the mount and while we were at that, we also updated the firmware of the hand controller. Once that is done, the GPS module is NOT visible to Ekos. But, as Jasem already explained, by simply selecting Mount Updates KStars swith both Time and Location selected we see that KStars uses the GPS location and time. The system time does not get updated though.
ASI6200 and filter wheel with a SkyWatcher Esprit 80 ED on a SkyWatcher HEQ5-Pro
ASI1600MM-Pro Cooled and filter wheel with an 8" TS Ritchey-Chrétien on a SkyWatcher EQ6-R


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Glass With Brown Liquor And Ice Cubes by Chris Stein - 5.5" x 8"
Luster Photo Paper
Rolled in a Tube
Glass With Brown Liquor And Ice Cubes art print by Chris Stein. Our art prints are produced on acid-free papers using archival inks to guarantee that they last a lifetime without fading or loss of color. All art prints include a 1" white border around the image to allow for future framing and matting, if desired.
Clean clear alcohol liquor glass full of large transparent ice cubes and half full with amber liquid in studio on a gray gradient background for... more
3 - 4 business days
Art Print Tags

domain: design


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By Euro Weekly News Media • 01 June 2015 • 15:10
JET2: Alicante passenger receives lifetime ban for disruptive behaviour.
AIRLINE Jet2.com has pledged to take a harsh line against any disruptive and inappropriate behaviour on board its flights, following a rise in in-flight incidents industry-wide.The zero tolerance policy comes after the airline has issued a lifetime ban to a male passenger who was headed to Alicante from Leeds Bradford Airport. The man was one of a party of 14 who was asked on numerous occasions to stop consuming illicit alcohol and to calm his behaviour with other passengers reporting his use of intimidating language and threatening behaviour.Jet2.com said: “Due to his unacceptable behaviour on board, the pilot diverted the flight to Toulouse where the disruptive passenger was handed over to the police authorities and the remaining travellers continued onto Alicante. As well as him delaying holidaymakers, he could now be facing prosecution for his behaviour and could be found liable for the costs of the divert, which will run into thousands of pounds.”Phil Ward, Managing Director of Jet2.com said the strong stance has been put in place to protect families and holidaymakers, ensuring every customer has a safe, enjoyable and comfortable flight without the worry of disruptive behaviour. It will cover all flights over 55 destinations across Europe.Unacceptable behaviour on board includes racist behaviour, threatening conduct towards passengers and staff, and excessive consumption of alcohol, any of which can result in police prosecution, refusal to board, flight diversion and a flight ban for life.
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Another nice video review of the Ruger P95 semi-automatic pistol. The Ruger P95 is chambered in 9mm and features ambidextrous safety/decocker and magazine release for both right and left handed shooters. The P95 has a polymer frame and steel slide with 3 dot sights but is a bit on the heavy side. Being a little big and heavy might be disadvantageous to CCW (concealed carry weapon) use but the other side of the equation is less recoil to the shooter and better accuracy. The trigger is double action/single action and it is hammer fired which gives you one more safety in my opinion. Check out the Ruger P95 pistol here!
Here is a table top review of my Ruger P95 that I bought in 2007. I’ve been shooting this gun for 4 years now and have grown to love this gun. It has an ambidextrous decocker and mag release, which is a great bonus to lefty’s like me. After a hard break in period this gun has been 100% reliable and fires like a champ. This is a great battle pistol, and a solid buy in the $300 range.
Here are some other handgun related sites you may want to check out. Thanks for visiting Best Handguns!
Regulation of Firearms in Wisconsin
N.J. Court Says Americans Have No Right To Buy Handguns ...
Top Choice Concealed Handguns | Reference.com
Bore brush | Define Bore brush at Dictionary.com
Handgun encyclopedia topics | Reference.com


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Once you order, you will get an email from your practitioner within 1-3 business days with our instructions, intake form, and FAQ file. The instructions will have information on how to take the hair sample and where to send it. Please fill out our intake form and return back to your practitioner through email as soon as possible (please do not send this to the lab with your hair sample!).
If you are getting a mailed HTMA kit (includes the paper scale for taking the hair sample more effectively and a small envelope for your hair sample), it can take about a week to get to you. Once you send your sample in to the lab, it can take about 2-3 weeks for us to get results back. Once results are in, Celeste will email you with your basic report and the link to schedule your phone consult, or you can request an email consult instead. After the consult, she will email over your written report and recommendations.
After your consult, you have 2 months of basic email support. This includes quick questions about your plan, updates, or any issues you might have with your plan. Please keep emails as short as possible so we can help you as best as we can.
If you’ve already had an HTMA with us and want to submit a review, you can do so here.
What is HTMA?
Hair tissue mineral analysis tests for crucial minerals like magnesium, potassium, sodium, calcium, zinc and copper. It also tests for toxic metals like mercury, arsenic, cadmium, and aluminum- all of which can create massive health issues. HTMA’s main focus is on the ratios of the main minerals. The ratios show us trends in metabolism, thyroid health, adrenal health, hormonal balance, blood sugar balance, and cardiovascular health. A properly read HTMA can help you to determine your gut function, liver health, if you’re using up nutrients due to stress (like infections, mold, etc), and more!
What HTMA Can Help you With
- Fixing Mineral Imbalances and Deficiencies
- Increase Nutrient Absorption
- Supporting Overall Detox
- Overall Health and Wellness
- Supporting Adrenal Health
- Strengthening Your Immune System
- Supporting Women’s Health During Preconception, Pregnancy, or Postpartum
What Our HTMA is All About
Whole Food Nutrition
We don’t use 1000 supplements in our plans! Our goal is to help you HEAL. Not to get stuck on supplements for the rest of your life. If you’re on 10-20 pills a day based on “nutritional needs”- that is NOT holistic and it can create more issues in the long run. We use a blend of food recommendations, herbal remedies, and other holistic health practices in our plans.
We work on basic foundational care that EVERYONE needs, no matter what your current health situation is. We work on gut healing, detox support, adrenal healing, and nutrient replenishment. These are are crucial to work on if you’re trying to heal from a chronic illness.
We tailor your plans for what YOU need as an individual. HTMA is an amazing tool, but for some reason it’s been used oddly for decades. They usually just make a supplement plan based on the lab’s recommendations- not on the person as an individual. I am one of the first people to do things differently and use HTMA the way it’s meant to be used- for biochemical individuality.
What is GI Map?
From Diagnostics Solutions Lab: “The GI-MAP™ (GI-Microbial Assay Plus) quantitatively assesses a patient’s microbiome with attention to bacterial, parasitic, and viral pathogens that can cause disease, disrupt the normal microbial balance, and contribute to chronic GI illness. “
GI Map tests for:
- Bacterial Pathogens
- Viral Pathogens
- Parasitic Pathogens
- Parasitic Protozoa
- Parasitic Worms
- Normal Bacterial Flora
- Opportunistic Bacteria
- H. pylori with Virulence Factors
- Immune Response
- Antibiotic Resistance Genes
Who should use GI Map?
If you are dealing with persistent gut health issues like IBS, constipation, diarrhea, autoimmune issues, SIBO, or you suspect viral infections and other pathogens, GI Map is the best way to determine exactly what is going on.
Since we need bile to properly eliminate pathogens, I highly recommend working on an HTMA plan or at least liver healing for at LEAST 3-6 months in order to get the best results with GI Map. Once we confirm the pathogens at hand, we will need to work on foundational care anyway before jumping into attack so it is best to start building this up first.
GI Map can help to determine many issues when it comes to the gut, so if you feel like you are stuck in your healing, it is the best test to go for.
When you order GI Map with us, you will get an email report with your results and the recommendations based on your test. If you are also doing an HTMA, then we will speak about the GI Map results as well.
Please be advised: they cannot ship or receive any kits from the state of New York. If they see any kit is being sent from New York, they cannot run the specimen and it will be rejected.
If ordering a GI Map or Mycotoxin test please put your date of birth in the notes box on the ordering page.
Mycotoxin Urine Testing
Mycotoxin Test- $375 USD
- The MycoTOX Profile screens for 10 different mycotoxins, from 40 species of mold, in one urine sample.
- The MycoTOX Profile is the most comprehensive and competitively priced mycotoxin test available.
- I am sorry but these tests are not available for those in the state of New York. If any kit is being sent from New York, they cannot run the specimen and it will be rejected.
- I highly recommend doing an HTMA first to start getting your foundation strong before embarking on any type of detox protocol. Usually 3-6 months of mineral balancing is ideal before starting to work on underlying issues like mycotoxins and pathogens.

domain: medical


Nicholas Valtz found dead in waters off Amagansett
Officials are investigating how a Brooklyn man died after family members found his body floating in the waters off Amagansett.
The body of Nicholas Valtz was found around 2 p.m. yesterday off Lazy Point.
Valtz's family says they went looking for the 39-year-old when he did not come back to his Bridgehampton home after going kiteboarding.
Valtz's body was found still attached...