text:
I did some annotation for some of the artists that I had in my sketchbook. When it comes to annotation, I'm usually terrible at it, and so, I always leave it to the last minute, which usually makes it worse. However as the year has progressed, I feel that my annotation is getting better, and I am not leaving it to the last minute as much.
I was thinking of using post-it notes in some way for this project, so I wrote out some examples and filled an entire page with them. I also thought of doing some drawings on post-it notes and started a portrait of Laszlo Biro.
This week we used the calligraphs we made form last week to make prints. I used the one that I made with the leave, but after multiple prints it started to disintegrate slightly because I had to keep on washing it.
We were also introduced to illustrator this week, and we were to use a self portrait of Egon Schiele, and then using the rectangle tool, make the shapes of the portrait and change their colour.
We went over the time plans we made over the last week and discussed materials and their cost. We then had a presentation about analysis of information, and then we had to make our own presentation. Our presentation was for us to analyse a photograph taken of the college in three different methods.
See you next week-
Róisín -x


text:
TQ Inspire Inc.
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- Stage Full Product Ready
- Industry Internet / Web Services
- Location Gilroy, CA, USA
- Currency USD
- Founded 2010
- Employees 1
- Website tqinspire.com
Company Summary
We provide unique and thought provoking contents based on truth that people care about and that may affect them as well as shine some light on the unknowns and open their minds in new ways at looking at things which can help them solve problems and inspire creativity & innovation. Our entertaining and enlightening contents leave them laughing, healthier, smarter and more curious! Our products help bodies, souls and minds--their overall beauties.
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The founder, Tiffany T. Quach has experience in product development, bringing companies live, partnering with manufacturers, experiences in building a distribution and a customer base. She is ideas developer and a trendsetter to leaders & individuals. We will harness this to create unique programs, and to gather entities and customers.

subset: commoncrawl


text:
Wednesday, April 18, 2007
I don't know what to make of the Burghosphere ...
I don't know what to make of the Burghosphere ... I mean, I hang out at and no doubt annoy about six to ten different blogs or so, commenting like I'm part of a conversation (http://jonathanpotts.blogspot.com/), trying to find a null space (http://nullspace2.blogspot.com/) in the chatter to jump into.
But it is really hard to take the whole thing seriously (credit to Bram for that phrase), because I see it as a group about the size of a classroom just talking to/at each other. This does not appear to be a significant part of the electorate, for example, and likely not representative of the electorate. Most everyone else in the Burghosphere is very well prepared and well read, and I don't mind being taken as opinionated and probably wrong. So, my views are my own and if my logic doesn't persuade you then its not strong enough and that's my fault. I'm open to being persuaded myself, except not really. I'm vain enough to think that unless someone shows me I'm wrong, I'm not wrong. 'course it is embarrassing how often people show me I'm wrong …
So this is leading in the direction of the on going Bodack/Dowd debate within the Burghosphere. I think I joined it early, posting about errors in email addresses and URL's in a flyer I got from Pat Dowd. There were also errors on the web page. I posted on that. A few days later on a Sunday Pat Dowd knocked on my door and chatted to me and my step daughter about what he wants to do. I was frankly impressed, and I posted on it. I picked up a commenter who was clearly a Bodack supporter and we commented back and forth for a while. Now, I can't say whether the accusations he has leveled at Dr.Dowd or his claims for Mr Bodack's record are accurate or not, though I have no objection to his making them. Since my commenter has chosen to remain anonymous, I have made the assumption that it is one person. There have been a variety of anti-Dowd and pro-Bodack posts around the part of Burghosphere I read, many with similar writing styles. So I wonder if/kind of think it is the same person.
Regardless, I am a Patrick Dowd supporter because I have been persuaded by what I have seen. Currently my support is a bit like those yellow support the troops ribbons on cars, almost entirely in name. And that is fine with me (if not with Dr. Dowd), that is the real world of work and obligations. But I have been willing to talk about why I think Dr. Dowd is the better choice, and I will continue to talk about it. Once again, I don't think many people read this site (and several have already abandoned this post), so even if I'm wrong I probably haven't done much harm. I kind of like Barack Obama too.
I think Dr. Dowd put in an appearance in the comments of my last post. I say "think" because there really is no way to verify, and I noticed the poster who is pro-Bodack has started appropriating names, including the name of this blog, while commenting on other blogs. Anyway, the commenter Dowd answered very neatly an accusation made by an anonymous commenter, who had selectively referenced an '05 PG story. And the real point of *this* post (there's a point?) is to note that the commenter Dowd referenced http://www.patrickdowd.org/, a website used by Dr. Dowd for his school board work.
Which leads me to this: the Dowd campaign came out early with a web presence, and Dr. Dowd already had a considerable web presence. Although DowdforPittsburgh initially was quite light on issues, it has filled out considerably. It has a blog which I wish Dowd or his handlers would delegate to someone else, because it's never been updated. But it also has video and pictures, press releases and so on, really as much as you could ask of any candidate. And patrickdowd.org existed prior to this campaign, and also has a huge amount of information. When Dr. Dowd talks about wanting to put transparency into government, well clearly he has already walked the walk. And once again, I can not find a Bodack campaign website, using Google on "Bodack". My anonymous commenter has done yeoman work (that's supposed to be a compliment) in filling in for this lack, with recent comments on the Burgh repore on a week old post, listing Mr. Bodacks accomplishments, and blasting the PG for endorsing Dowd. And I should note Mr. Bodack is one of a minority of council persons who have put there finances on the web. But the lack of a campaign website is, for me, enough to keep me from voting for Mr. Bodack, at least versus Dr. Dowd.
14 comments:
Just a quick note to verify that it was me. We met in the colder days of the year. You invited me into your house which is on the corner of...well, I better not reveal that without your permission. Your porch is green, if I remember correctly. Your front door opens directly into a carpeted living room.
Please note that I tried to publish regular updates to constituents. These can be found under "comments" at www.patrickdowd.org. Because I have no budget or staff as a school board member, I funded this with left over campaign contributions (see financial filings for Citizens for Patrick Dowd). I also tried to keep newslinks up-to-date. I intend to keep up this connection plus would mail to folks not interested in electronic newsletters. There is a cost issue here that would need to be addressed but I would certainly maintain a non-government funded website for this kind of connection.
- April 18, 2007 1:13 PM
- EdHeath said...
- This comment has been removed by the author.
- April 18, 2007 9:51 PM
- EdHeath said...
Just getting the spacing right ...
Well, I was pretty sure it was you, but didn't want to assume. Shouldn't you be grading papers? I can see a lot of work went into patrickdowd.org, and I believe it is a clear model for what we could expect from you as a councilman. But I am even more impressed with dowdforpittsburgh, just because I have been so disappointed with other candidates' websites in this campaign. Oh, and I was wrong about the blog on your website, it is absolutely updated. Only with the contents of the emails your campaign puts out, but it is up to date (I don't know if my browser was having some refresh problem or I just misread).
If I have your attention, a brief thought. Isn't there a Pittsburgh based healthcare initiative? It was in the paper in the last couple of weeks, I believe. I think they should be approached. If city workers and retiree's could be put on a healthcare plan that really emphasized prevention, rewarded good behavior and nagged/punished bad health behavior, the benefits in regained performance might pay for the additional cost. I'm pretty sure I have blogged on this before, how the guy who invented the South Beach Diet turns out to be a cardiologist whose patients have almost no heart disease. It's not (just) because of the famous diet, the doctor's practise loses money (he can afford it) because they are so aggressive with their patients in monitoring their health. There has to be a way to help patients self monitor and help them to take action, a "sweet spot" for budgetary purposes.
This might be part of suggestions the city could make to reduce PAT's labor costs. This might be a one time savings, but having a work force in optimal health would be a big plus for both the city and the Port Authority. Of course, you would have to find an insurance company willing to under-write such a plan.
- April 18, 2007 10:00 PM
The city has no power but to make suggestions regarding the "county" transit system. Setting a framework for a vision for a transit system where all stakeholders have a say in the elimination of routes is the city's responsibility. City Council has the legislative jurisdiction to leverage the county into making the tough choices while ensuring everyone is happy with the cuts because we are the regional hub for all activity, Jeeze, does this say anything? The city has no legal jurisdiction over county operations, we are a seperate entity. If you have one, make a suggestion, you dont need to be elected to office to do so. Dont you think there are intelligent people working on this issue or do you think Patrick Dowd is the only person with a brain. Case in point the 17 million in cost savings revealed today. This decision wasnt made in a vacuum, Onorato and the Port Authority are aware of this. Did you ask yourself if the drivers union would agree to this change? Should the working man be made to accept less because of the abuses of management. Those gains were won through hard fights, on a picket line, while management types wasted millions. Your republican attitudes and values dont fit here and you'll never understand this viewpoint because you have never walked in those shoes. If you want real change ask the non-profits to pay their fair share and get your friends at the Post-Gazette to agree to do the same.
- April 19, 2007 9:32 PM
I know Dowd frequents this site so I come here for an honest answer. Is it true that you agreed to a compensation package for Mark Roosevelt that will allow him to make $240,000 in his last year?
- April 23, 2007 7:30 PM
- smallstreams said...
The Burghosphere is out there (here?) and paying attention. Councilman Bodack, where are you?
- April 23, 2007 10:30 PM
- EdHeath said...
I expect these things are a matter of public record. You could also check patrickdowd.org, and decide for yourself. Which again is part of the point, that this is a model for city government. For what it is worth.
- April 23, 2007 11:11 PM
- Matt H said...
It would be nice to see the question answered.
- April 24, 2007 1:58 AM
- EdHeath said...
Matt, you don't want the "did this happen" question answered, we all know it did (http://www.post-gazette.com/pg/07094/774858-192.stm). You want the "how could you waste our taxpayer dollars" question answered. This was a 7-2 board decision, but Dr Dowd is the only school board member running for city council in the 7th district, making him a target for this question. Still, I think Dr. Dowd would say that Mr. Roosevelt met the goals set for him by the school board. The increase in superintendent's pay nationwide seems fairly well documented, like the increase in college president's salaries. I guess the PG opinion piece I reference above makes a good point about the school district being in the middle of change and needing stability. Still, maybe the board should for a local person for the next superintendent.
- April 24, 2007 8:20 AM
If you look at my 2003 campaign promises I said I would focus on bringing the board together, on building a better relationship between the board and superintendent and holding the superintendent accountable for the performance of the district. If you ask my colleagues at the Pittsburgh Board of Education about my role in crafting a new superintendent contract, they will likely tell you that I was at the center of that reform driving important changes that ultimately helped solidify a stronger, more cohesive relationship between the board and superintendent. For purposes of comparison, check out the following links and compare contracts.
John Thompson's Contact
Mark Roosevelt's Contract (August 2005)
Mark Roosevelt's Contract (March 2007
You can also review Superintendent Roosevelt's first year evaluation and the board resolution approving the change in his salary between Year 1 and Year 2.
Superintendent Roosevelt's Year 1 Self-Evaluation
Resolution on Superintendent Roosevelt's Year 1 Performance
Board Established Performance Priorities for Superintendent Roosevelt's Year 2
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- March 29, 2018 9:53 PM
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- July 05, 2018 9:11 PM


text:
As I type this my fingers are jumping over hurdles of books, stationary and empty CD covers. My hands are navigating streets lined with papers and perfume and even a dragon bought in Thailand, just to get to the keyboard. My room is a mess and my house is a war-zone of different factions fighting each other. I think the tools and camping gear is launching an attack on the stuff-I-want-to-give-to-the-hospice-shop pile but I am too scared to look. The hammer and four nails that just rolled defeated into my bedroom is probably not a great sign.
Why oh why did I keep clothes that I last wore in my final year of school. Was I so sure that I would drop two sizes on my diet of coke, cheese and eating chocolate sauce out of the bottle? Also what is with all the magazines, did I really think that one morning I would wake up and want nothing more than to read a car magazine that is four years old.
|My fridge in Japan: yeah I still love myself some cheese.
|Not Keisuke, but the car we traded him in for.
|The car I wish I drove
|Me freezing in good old Keisuke
|My first apartment in Japan!
It is best that I get back to packing now, since I think I see the photo frames building a rudimentary shelter out of computer boxes to shield themselves against the coming invasion of the crockery. Wish me luck.


text:
End-of-life (EoL) care is a major component in the management of patients with advanced COPD. Patient-physician communication is essential in this process.Aim
To evaluate the practice of Portuguese Pulmonologists in EoL communication and palliative care in COPD.Methods
An on-line survey was sent to physicians affiliated to the Portuguese Pneumology Society.Results
We obtained 136 answers from 464 eligible participants (29.3%). About half of the physicians reported that they have rarely introduced EoL discussions with their COPD patients (48.5%). Most had never/rarely suggested decision-making on the use of invasive mechanical ventilation (68.4%). Discussions were described as occurring mostly during/after a major exacerbation (53.7%). Only 37.5% of participants reported treating dyspnoea with opioids frequently/always. Only 9.6% stated that they never/rarely treated anxiety/depression. Most participants perceive the discussion of EoL issues as being difficult/very difficult (89.0%). The reasons most frequently given were feeling that patients were not prepared for this discussion (70.0%), fear of taking away a patient's hope (58.0%) and lack of training (51.0%).Conclusion
Patient and medical staff EoL communication in COPD is still not good enough. Training in this area and the creation of formal protocols to initiate EoL have been identified as major factors for improvement.
Os cuidados terminais (EoL) são um componente importante do tratamento de doentes com doença pulmonar obstrutiva crónica (DPOC) avançada. A comunicação entre o doente e o médico é fundamental neste processo.Objetivo
Avaliar a prática dos pneumologistas portugueses na comunicação sobre o fim de vida e os cuidados paliativos na DPOC.Métodos
Foi enviado um inquérito online para os médicos sócios da Sociedade Portuguesa de Pneumologia.Resultados
Recebemos 136 respostas dos 464 participantes elegíveis (29,3%). Cerca de metade dos médicos indicaram que raramente iniciaram conversas sobre o fim de vida com os seus doentes com DPOC (48,5%). A maioria nunca/raramente sugeriram a toma de decisão sobre a utilização de ventilação mecânica invasiva (68,4%). As conversas foram descritas como ocorrendo, na sua maioria, durante/após uma exacerbação grave (53,7%). Apenas 37,5% dos participantes indicaram tratar a dispneia frequentemente/sempre com opiáceos. Apenas 9,6% indicaram que nunca/raramente trataram a ansiedade/depressão. A maioria dos participantes considerou a conversa sobre questões de fim de vida como sendo difícil/muito difícil (89,0%). Os motivos mais frequentemente indicados foram a sensação de que os doentes não estavam preparados para essa conversa (70,0%), medo de tirar a esperança aos doentes (58,0%) e falta de formação (51,0%).Conclusão
A comunicação sobre o fim de vida entre o doente e os médicos na DPOC ainda não é suficientemente boa. A formação nesta área e a criação de protocolos formais para iniciar os cuidados em fim de vida foram identificados como fatores importantes a melhorar.
Chronic obstructive pulmonary disease (COPD) is a chronic and progressive disease that in its advanced stages may be associated with important physical, psychological and social impairments. Palliative care should be provided to advanced COPD patients so as to reduce the high burden of chronically debilitating symptoms such as dyspnoea and anxiety.
Patient–physician communication on prognosis, preferences for life-sustaining treatments and palliative care, is essential to ensure that COPD patients receive end-of-life (EoL) quality care that is consistent with the values upheld. The uncertain disease trajectory, which frequently involves unexpected deterioration in health status, makes planning of care in advance essential.1
In recent years, there has been a growing interest in EoL care in advanced COPD. Some important scientific societies have published recommendations on this theme and the Global Initiative for Obstructive Pulmonary Disease (GOLD) introduced it for the first time into the 2013 updated revision.2–4 The challenge remains in how EoL care is implemented in practice. At present, there is evidence that COPD patients receive poor EoL care and that there is insufficient patient-physician discussion on EoL preferences.5,6
We developed a survey to characterize the Portuguese Pulmonologists' practice in EoL communication and palliative care in advanced COPD patients, and identify hurdles to its consistent implementation. With this study, we hope to help establish strategies to overcome the difficulties that physicians face in their every-day practice, which ultimately may lead to an improvement on the EoL care that COPD patients receive.MethodsParticipant recruitment
In January 2013 we asked the Portuguese Pneumology Society (SPP) to provide us with the mailing list of all affiliated Respiratory Medicine specialists and fellows with email contact. We obtained a list of 464 members. We only asked physicians who had had clinical activity in the previous year to answer the survey.Questionnaire development and administration
A self-administrated questionnaire was developed specifically for this study. The authors generated questions based on a review of the literature. Questions were drawn up to address four main themes: (1) palliation of symptoms; (2) frequency and topics of EoL communication; (3) timing and interveners of EoL communication; (4) obstacles to EoL communication.
The following data were collected to characterize participants: age, gender, religious beliefs, years of practice, type of institution, region of the country and number of patients with COPD treated per year.
At the beginning of the questionnaire, participants were asked to answer questions with reference to the patients they had treated in the previous year, who had two or more of the following characteristics: forced expiratory volume in first second (FEV1) under 30%, oxygen dependence, one or more hospital admissions in the previous year for an acute exacerbation of COPD, left heart failure or other comorbidities, weight loss or caquexia, decreased functional status, increasing dependence on others and were over 70 years old. We adopted these criterion from Curtis, whose purpose was to identify patients in whom a discussion on preferences about EoL care should be initiated.5
We pretested the questionnaire on a convenience sample of 6 pulmonologists to ensure clarity and comprehensiveness. A web platform was then designed to facilitate survey completion and data collection. Participants received an invitation to answer the questionnaire via an e-mail sent by the SPP, containing a link to the online platform. One month was allowed for questionnaire completion. During the one month period two e-mails of reminder were sent to each applicant, after which time the website was closed. All complete questionnaires were considered eligible so that we are characterizing the reality of our practice.Statistical analysis
Demographic data and the several variables related to palliation and communication were analyzed using descriptive statistics. To verify a possible influence of the participant characteristics on their ability to undertake EoL communication, a univariate analysis was performed between the main characteristics – years of practice, type of institution (university hospital vs other), number of COPD patients treated – and two questions evaluated by a semi-quantitative scale: (a) "How often have you started a EoL discussion on your initiative?"; (b) "How difficult is it for you to discuss EoL issues with your patients?". Statistical significance values were set at p≤0.05.Results
From the 464 eligible participants, 136 completed the questionnaire (participation rate of 29.3%). Characteristics of respondents are summarized in Table 1. Most respondents (52.2%) had treated 50–200 COPD patients in the previous year.
Participant characteristics.
|46.0 (±12.1)
|Gender: female
|83 (61.0%)
|Religious beliefs
|83 (61.0%)
|34 (25.0%)
|"I prefer not to answer"
|19 (14.0%)
|Years of practice
|18 (13.2%)
|27 (19.9%)
|6 (19.1%)
|44 (32.4%)
|21 (15.4%)
|Type of institution
|University hospital
|54 (39.7%)
|Other hospital
|71 (52.2%)
|Primary health-care unit
|2 (1.5%)
|Private medical clinic/office
|9 (6.6%)
|Region of the country
|39 (28.7%)
|17 (12.5%)
|Lisboa and Vale do Tejo
|67 (49.3%)
|5 (3.7%)
|6 (4.4%)
|Madeira and Açores
|2 (1.5%)
|Number of COPD patients treated in the last year
|33 (24.3%)
|71 (52.2%)
|32 (23.5%)
|Number of COPD patients treated in the last year with 2 or more of the Curtis?? criteria
|74 (54.4%)
|47 (36.4%)
|15 (9.2%)
|Number of EoL articles read in the last 6 months
|53 (39.0%)
|56 (41.2%)
|18 (13.2%)
|9 (6.6%)
|Number of post-graduate courses on EoL attended
|69 (50.7%)
|49 (36.0%)
|12 (8.8%)
|6 (4.4%)
Data are presented as n (%) or mean (±standard deviation); EoL=end-of-life; COPD=chronic obstructive pulmonary disease.
We questioned physicians about the number of patients that would not cause them surprise if they died in the following year. Seventy-one (52.1%) would not be surprised if up to 30% of their patients died in the following year, 56 (41.1%) admitted that 30–69% could die in that period, and only 9 (6.8%) considered this possibility in 70% or more patients.
Concerning palliation, we asked physicians how often they treated pain, dyspnoea (namely with opioids) and depression/anxiety. Results are summarized in Table 2. The use of opioids to manage dyspnoea was reported to occur occasionally in 32.4% of cases and frequently/always in 37.5%. Respondents indicated they treated anxiety and depression frequently/always in 43.4% of cases.
Palliation of symptoms.
|How often treated
|Dyspnoea (namely using opioids)
|12 (8.8)
|29 (21.3)
|44 (32.4)
|41 (30.1)
|10 (7.4)
|Pain (namely using opioids)
|20 (14.7)
|20 (14.7)
|62 (45.6)
|23 (16.9)
|11 (8.1)
|5 (3.7)
|8 (5.9)
|64 (47.1)
|50 (36.8)
|9 (6.6)
Data are presented as n (%).
The frequency of EoL communication and the topics are presented in Table 3. Most physicians (61.7%) said they had rarely or never initiated this type of discussion. The progression of disease was the topic most discussed by physicians with patients, but life expectancy and the suffering related to death were less often approached. Most respondents also claimed to have never or rarely asked about patients' spiritual or religious beliefs (81.6%).
Frequency and topics of EoL communication.
|How often started by own initiative a EoL discussion
|18 (13.2)
|66 (48.5)
|34 (25.0)
|12 (8.8)
|6 (4.4)
|How often discussed
|The evolution of the disease
|8 (5.9)
|29 (21.3)
|55 (40.4)
|29 (21.3)
|15 (11.0)
|Life expectancy
|33 (24.3)
|62 (45.6)
|28 (20.6)
|7 (5.1)
|6 (4.4)
|How death can be/related suffering
|37 (27.2)
|54 (39.7)
|35 (25.7)
|8 (5.9)
|2 (1.5)
|Patient's spiritual or religious beliefs
|58 (42.6)
|53 (39.0)
|20 (14.7)
|2 (1.5)
|3 (2.2)
|How often suggested patients to make decisions about
|Invasive mechanical ventilation/intubation
|39 (28.7)
|54 (39.7)
|27 (19.9)
|10 (7.4)
|6 (4.4)
|Cardio-pulmonary resuscitation
|58 (42.6)
|52 (38.2)
|15 (11.0)
|6 (4.4)
|5 (3.7)
|Place of death
|58 (42.6)
|45 (33.3)
|24 (17.6)
|5 (3.7)
|4 (2.9)
|How often suggested the elaboration of a written in advance directive (living will)
|109 (80.1)
|19 (14.0)
|8 (5.9)
|0 (0.0)
|0 (0.0)
|How often referred to hospice care
|21 (15.4)
|41 (30.1)
|58 (42.6)
|16 (11.8)
|0 (0.0)
Data are presented as n (%); EoL=end-of-life.
Regarding EoL decision-making, the majority of participants said they never/rarely suggested their patients to make decisions about invasive mechanical ventilation/intubation (68.4%), cardio-pulmonary resuscitation (80.8%) or whether they preferred to die at home versus in hospital (75.9%). Most had never suggested the drawing up a written advance directive (80.1%), although almost all of them (95.6%) were aware that the Portuguese law provides for this possibility. Only 11.8% reported to have frequently referred COPD patients to hospice care services.
We also inquired of participants what moment was usually chosen for EoL discussion. Discussion was reported to occur during a major exacerbation in 29.4%, in advanced disease when the patient is stable in 25.0%, after the patient survives a major exacerbation in 24.3%, only if patient or caregiver introduces the subject in 14.0% and early after diagnosis in 7.4%.
Interveners usually included in EoL discussion are listed in Table 4. Among healthcare professionals, other physicians were the main interveners, followed by nurses. Most (91.0%) respondents indicated that they never or rarely include religious advisors. About half (57.4%) claimed to frequently/always include relatives.
Interveners in EoL communication.
|How often included other interveners in EoL discussion
|Other physicians
|12 (8.8)
|30 (21.1)
|46 (33.8)
|28 (20.6)
|20 (14.7)
|33 (24.3)
|42 (30.9)
|35 (25.7)
|21 (15.4)
|5 (3.7)
|56 (41.2)
|30 (22.1)
|36 (26.5)
|12 (8.8)
|2 (1.5)
|62 (45.6)
|30 (22.1)
|36 (26.5)
|7 (5.1)
|1 (0.7)
|Social workers
|46 (33.8)
|30 (22.1)
|35 (25.7)
|23 (16.9)
|2 (1.5)
|Religious advisor
|83 (61.0)
|41 (30.0)
|10 (7.4)
|2 (1.5)
|0 (0.0)
|Patient's caregiver/family
|2 (1.5)
|16 (11.8)
|40 (29.4)
|45 (33.1)
|33 (24.3)
|How often discussed EoL issues only with caregivers/family, and excluded the patient
|44 (32.4)
|39 (28.7)
|42 (30.9)
|8 (5.9)
|3 (2.2)
|How often changed the information given to patients or their caregivers/family in order to influence decision
|87 (64.0)
|37 (27.2)
|10 (7.4)
|1 (0.7)
|1 (0.7)
|How often decided on EoL only with health professionals, without including patients or their caregivers/family
|33 (24.3)
|53 (39.0)
|33 (24.3)
|16 (11.8)
|1 (0.7)
Data are presented as n (%); EoL=end-of-life.
When asked how often they excluded the patient and discussed EoL only with caregivers, most (61.1%) claimed to have never/rarely done so. Also, 63.3% indicated they never/rarely made EoL decisions just with health providers. Most (64.0%) claimed to have never changed the information given to patients/caregivers in order to influence decision according to what they believe is best, and from the remaining, most said they only did this rarely (27.2%).
We questioned closely as to how difficult it was for physicians to hold EoL discussions with their patients. Twenty-seven answered it was very difficult (19.9%), 94 said it was difficult (69.1%), 4 were indifferent (2.9%), 8 said it was easy (5.9%) and 3 very easy (2.2%). From a 7-item list, we asked them to select all the difficulties usually felt in EoL discussions. Results are summarized in Table 5.
Obstacles to EoL communication.
|n (%)
|Feel that patients are not prepared to discuss these issues
|95 (69.9%)
|Fear of taking away patients' hope
|78 (57.4%)
|Lack of training in this area
|70 (51.5%)
|Lack of support/organization in the work institution
|52 (38.2%)
|Lack of time
|52 (38.2%)
|Difficulty in predicting progression of patient's disease
|48 (35.3%)
|Fear of legal repercussions
|8 (5.9%)
|5 (3.7%)
Data are presented as n (%); EoL=end-of-life.
We inquired about the participants' opinion on the importance of discussing EoL with advanced COPD patients. Most (76.5%) rated it as very important, 31 (22.8%) as a subject of some importance, with only one participant indicating that it was of little importance. Finally, we asked if participants would like this subject to be further discussed in scientific meetings. Almost all (98.5%) agreed, and only 2 (1.5%) respondents claimed that the issue is being sufficiently addressed already.
There were no statistical significant differences between years of practice, type of institution or number of COPD patients treated and the main outcomes.Discussion
Despite the increasing interest on EoL communication and palliative care in end-stage COPD, this is, to our knowledge, the first study performed in Portugal to evaluate Pulmonologists?? perception of this matter.Palliation of symptoms
Although the majority of physicians reported that they treated symptoms at least occasionally, our findings suggest that symptom management may not be optimized. Only a few reported using opioids routinely in the treatment of dyspnoea and pain. Since opioids are the only drug proven to be effective in controlling dyspnoea in these patients, these results are clearly unsatisfactory.7 Previous studies have shown evidence of poor palliation in COPD.8–10 The study SUPPORT, for instance, revealed that dyspnoea occurs more often in these patients than in lung cancer patients. In the same study, 21% of patients with COPD reported suffering from severe pain.10 There is a strong possibility that analgesics are withheld in COPD because of concerns about adverse effects, in particular respiratory depression. This fear is unfounded, since there is no evidence to date that the doses of opioids used to treat breathlessness causes clinically detectable respiratory depression or increases mortality.7
It has been suggested that anxiety/depression affects as many as 90% of advanced COPD patients, but previous studies have reported that only 4–31% were receiving pharmacological treatment.11,12 We found a better performance, which may reveal a rising awareness of the beneficial effects of antidepressants in improving mood and decreasing dyspnoea in COPD patients.13 Treating depression is essential since it may modify patient decisions concerning EoL care.14Frequency and topics of end-of-life communication
Another important outcome of this study was to realize that more than half of Portuguese Pulmonologists never or rarely introduce EoL discussions with their patients. Previous reports, both from physician and patient point of view, have also shown insufficient EoL communication.15–17 One of the topics most neglected by physicians was spiritual/religious beliefs, although there is evidence that the majority of patients want to discuss these issues.18
Although advance care planning seems to increase patient satisfaction and reduce emotional distress, our results show that physicians have used little initiative in introducing it.18 The lack of certainty on prognosis strengthens the need for advance directives in COPD, but the evidence is they are rarely used. A Survey carried out in the European Respiratory Intermediate care units showed that only 30% of patients admitted to having had a formal discussion about EoL decisions and/or signed a living will.19 As a result, COPD patients are more likely to die with aggressive, technological care directed at preservation of life and less likely to receive palliative care, despite having preferences favouring palliation.10 In fact, the majority of COPD patients die in the hospital, mostly in intensive care units, although at least half of clinically stable advanced COPD patients would prefer to die in their home environment.8,20
Hospice care in end-stage COPD is another emerging issue. The recent revised version of GOLD recommends that clinicians should identify COPD patients who could benefit from palliative care services and help find available resources within their community.4 In our study, about half the respondents indicated they occasionally/frequently refer patients to hospice care. Nonetheless, patients dying of end-stage COPD are in general less likely to be offered hospice services compared to patients with lung cancer.5 Uncertainty about prognosis as well as doubts as to whether a traditional hospice model is suitable for patients with COPD, may explain this difference, although it should not impede access to hospice care.2Timing and interveners in end-of-life communication
Recent consensus recommends that EoL care should be available early during the course of the disease, from when the patient becomes symptomatic.3 However, contrary to this, we found that most physicians discuss it during/after a major exacerbation. Another study also reported that discussions occur mainly in advanced stages of COPD, that is when dyspnoea became severe.21
There are more growing recommendations on the use of interdisciplinary health-care teams to ensure quality EoL care.2 Nonetheless, we found poor interdisciplinary work in our study. Results were similar in the previously mentioned European survey, which found that nurses were involved in 55.9%, but only in a small minority of cases were opinions sought from other professionals. In the same study, patient's relatives were involved in discussion in only about half the cases.19 We in turn, found a better performance in terms of engaging the family, although often without patient participation. Interestingly, our participants rarely reported modifying the information provided in order to influence decisions, a phenomenon that was reported to commonly occur in previous studies.21,22Obstacles in end-of-life communication
Most participants described the discussion of EoL issues as being difficult or very difficult, which makes it essential to understand what the barriers are that physicians face, especially the ones that can be modified.
As in a previous study, the feeling that patients may be unprepared to discuss these matters and the fear of taking away their hope, were pointed out as major obstacles to communication.17 Patient failure to understand COPD as a life-threatening disease and their will to concentrate on staying alive play an important role in this process.17 Cultural differences possibly have an influence as well. In a European survey evaluating public preferences for self-involvement in EoL decision-making, about 60% of the Portuguese participants wanted to be involved, which was less than the European mean (74%).23 These barriers may be overcome with education about illness progression and encouragement to communicate.
Other obstacles mentioned by our respondents have to do with organizational aspects, namely lack of time, lack of training and absence of protocols. The lack of formal protocols to initiate EoL was also pointed out by Partridge et al.24 Additionally, educational practices are inadequate, as revealed in a survey performed in the United States.25 These aspects represent important targets for intervention. Each institution should develop policies to guide health staff in initiating the kind of EoL care that is feasible in their context.2 Scientific societies, in their turn, are responsible for ensuring that there is appropriate education on EoL care in medical schools and for promoting continuous education among attendant health-care givers. There is evidence that educational programmes and even smaller interventions result in measurable improvements in communication skills.26–28 Moreover, our study demonstrates that Pulmonologists are interested in further education on this subject.
Limited resources are a significant impediment to effective EoL care. In Portugal, the need for fiscal consolidation has led to major cuts in the financing of the health sector in recent years.29 Despite the National Program for Palliative Care which was created in 2010, numbers show that resources (regarding number of hospice care beds and the availability of domiciliary services) are still far behind recommendations by the European Association for Palliative care.29 These restrictions are recognized by Portuguese citizens, who call for more hospital palliative care units and more palliative care access.30 Evidence-based service development using existing resources may be part of the solution.6
According to our results, the particular characteristics of a physician do not seem to influence their ability to communicate on EoL issues, which suggests that the barriers identified are transversal to different practice settings.Limitations and conclusions
The present study has a number of potential limitations.
The Curtis criterion to identify candidates for EoL discussion may be subject to criticism. It is a presumptive criterion, since it has not been proven that patients who are included die sooner or have more symptoms. Other proposed criteria, namely the CART and BODE scores, both able to predict mortality in patients with COPD, would be equally valid.31–33 Nonetheless, we believe the former is more suitable for the purposes of this type of questionnaire, since it includes a list of clinical characteristics, which are easier to answer with a yes/no response, when mentally profiling the type of patients. Whereas CART is a tree-algorithm and BODE requires a numeric grading of each variable, both of which cases would make this process more difficult.
Concerning the use of opioids in the treatment of dyspnoea, we retrospectively realized that the question should have been put in a more objective way. Since current recommendations to treat dyspnoea include a multimodal approach, we recognize that the way the question was phrased may not reveal the true scale of opioids use for this purpose.
We recognize that our participation rate was low. However, our universe included an unknown number of retired physicians, who were asked not to answer the questionnaire, and thus underestimated the overall response rate. Also, the choosing to use a web platform to perform the survey, may have influenced the response rate and the profile of the respondents.
Another obvious limitation is that the self-reported information may not reflect what Pulmonologists actually do in practice. Future studies should find ways of quantifying EoL communication more objectively, while recognizing that research in this area is hampered by important ethical and methodological challenges.34
In conclusion, our study demonstrated that our palliative care and EoL communication are a long way from being from what they should be. Awareness, training in this field and the creation of formal protocols have been identified as major areas for improvement, and should be encouraged. Future studies should focus on developing and testing the effectiveness of practical strategies to improve EoL communication and palliative care in COPD.Ethical disclosuresProtection of human and animal subjects
The authors declare that no experiments were performed on humans or animals for this study.Confidentiality of data
The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.Right to privacy and informed consent
The authors declare that no patient data appear in this article.Conflicts of interest
The authors have no conflicts of interest to declare.
The authors would like to thank the Portuguese Society of Pulmonology for providing us the contacts of their affiliates and inviting them to participate in this survey.
This study was performed at: Serviço de Pneumologia do Centro Hospitalar Lisboa Norte, EPE - Hospital Pulido Valente, Lisbon, Portugal.


text:
Reports on the Durban, South Africa Conference 2017
Report by Shailen and Mel Singh
Dr Jonathan David as a wise master builder sent a clear mandate to the South African Church in preparation for ASSIGNMENT – 5 STONES.
"South Africa will be moving to the Next Level. This is an Apostolic work and mandate for a New South African Church. Your spirit will respond to the Holy Spirit frequency and learn to contribute your quota for this Reformation of the Church and the Transformation of the Nation. I will show you how powerful strategies are being put in place so that you can:
Is the South African church ready for the ABOVE said ASSIGNMENT – 5 STONES? This is the Code Name. We will see DEMONIC GIANTS FALL, GIANT CORPORATIONS BECOME GIVERS INSTEAD OF TAKERS, CORRUPT GIANT POLITICIANS FALL, GIANT MINISTERS IN THE CHURCH FLEE COS' THEY HAVE BEEN EXPOSED. The Church Unusual will rise like a SLEEPING GIANT AWAKENED." – Dr. Jonathan David
Papa Jonathan David and Mum Helen's visit to Durban South Africa was a kairos visit with the nation experiencing the contractions of transition. God is truly taking the nation to another level in Him, in order to raise other nations in the African Continent. The preceding season was characterized by prayer movements across the nation with the highlight been the prayer spearheaded by Angus Buchnan with over a million people in attendance. South African churches were mobilized to pray nationally and hence the portal of heaven was opened to receive heavens instruction from Papa.
Interview at Highway Radio
On the morning of the 29th August, Papa Jonathan was hosted by Highway radio talk show and he was interviewed by DJ Malunge Myende on his South African Assignment. Highway Radio is a well-known Christian station that ministers to 400,000 listeners every day. Dr JD declared that this is a strategic time for South Africa in a very powerful interview. The interview focused on the prophetic word released over South Africa and also provided an overview of God's word that was to be shared in the Durban Conference. Dr Jonathan David also encouraged the Fivefold ministry and Body of Christ to stay on course for the destiny of South Africa.
Building Church, Birthing Zion and Becoming Kingdom Execution of Kingdom Assignment
People responded to the clarion call to Building Church, Birthing Zion and Becoming Kingdom at Sastri Academic Convention Center. Pastors and leaders converged from South Africa and other African nations.
1st day Durban Conference
The Durban Conference is officially opened on the 31 August by the Deputy Mayor of Durban, Mrs. Fawzia Peer, a well-recognized government official who has been serving passionately as a council leader in Durban for 20 years.
As South Africa is in a cross road and much uncertainty about her future, the people in Durban and South Africa are very pleased to receive Dr Jonathan David and to hear from him clear a prophetic word over their nation. There are many pastors and leaders from various denominations in the Conference together with our ISAAC churches in KZN and other regions. There is a sovereign move to bring nations back to destiny. Papa declared equalization in the nation. The next two terms God will redefine the flow in government and in 2029 a new leadership will arise and the nation will be taken without bloodshed. God will position strategic righteous men and we will see a manifestation of the Cyrus Factor.
The word declared brought much assurance of God's hand upon South Africa and His intention to intervene into the affairs of men and to bring in a fresh and strategic move into this nation. The Church in South Africa must rise and come out of her cave and prepare herself with a clear assignment from God to be actively involved in the building of this nation. This word declared is new to many pastors present but it is well received. A new day is dawning for a new South Africa to arise.
2nd day of Durban Conference
God is challenging the Church here to cross over and to take over. He is taking the Church on a new journey to plunder the works of the enemy. This proceeding word is new to many hearers and the Holy Spirit is continually tuning their frequency to His word. Strength and faith for the journey is breaking through. There's a new breed coming forth that is willing to take the challenge to launch into the deep and to take back what was lost. There must be a reformation of the Church for transformation of the nation. The Church was summoned to embrace equalization in the Spirit and send out accurate frequencies for convergence and globalization. This will manifest through Holy Spirit.
More pastors wanted to be connected and to learn more. Durban needs more strategic men and women to lead the move of God in this region. We are seeing the will of God coming into reality. The spiritual atmosphere is becoming more charged with the intensity of the Spirit as God's people become aware and respond to embrace the plan and purpose of God for their city and nation.
3rd and final day of Durban Conference
The final day of the Conference ended at a climax with about 800 participations. The final session is catered for the youth, between the ages of 17 – 30 years, who will soon be our next generation of leaders. Present at the session was ISAAC GOLD mentees that expressed gratitude to Papa and mum for their personal investment in their lives and contribution to their development.
Dr Jonathan David continued to challenge the Church here to rise to her stature to become giant slayers and city takers. The city cannot be built without the materials of righteous men that the church needs to supply. The role of the church is vital to see the reality of a new South Africa. This young generation are inspired to rise and become agents of change to make a difference and take their responsibility to advance the Kingdom of God and His righteousness.
Sunday Cerebration with Combined ISAAC KZN churches
More than 1000 members from various ISAAC churches all over Kwazulu Natal province worshipped together at the Conference venue to hear God's word by Dr Jonathan David.
Dr Jonathan David taught the ISAAC churches on operating the God kind of faith in order to fulfill her God given assignment for their community and nation. God's church will also receive the Samuel's anointing which is a governing grace with the power to prevail against the works of the enemy.
DURBAN: A "messenger from God", who was in Durban the past week, prophesied better days ahead for South Africa in the next 10 years.
The presiding apostle of Isaac (International Strategic Alliance of Apostolic Churches), Jonathan David, believes good things will take place in South Africa, including improved social cohesion and an end to corruption among leaders.
The Malaysia-based pastor has been addressing large audiences during the KwaZulu-Natal leg of the Isaac leadership's visit to South Africa.
Isaac is a company of senior ministers and missionaries who have an alliance with David as their primary source of governance over their lives, ministry and churches.
Pastors from across the country and Africa, corporate leaders and politicians attended the first of several sessions at Sastri College in Durban last week, which was opened by deputy mayor Fawzia Peer.
David told congregants: "A new day is dawning for a new South Africa to arise."
For more than 20 years, David, who is believed by his followers to have a spiritual link to the divine, has been mentoring pastors and leaders through the Isaac network.
He prophesied that in the next decade, corruption among the nation's leaders would be exposed and social cohesion would improve.
He said: "From underneath His feet is emerging a generation of men and women who are the true Rainbow Nation as faces without races."


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Dunno about you, but for us, summer's best times often happen with the sand and surf as a backdrop. Whether eating and drinking, riding the waves or just basking in the sun, grab some of this stuff to make the most of your next trip down the shore.
Hydro Flask 16 oz. True Pint ($24.95): The perfect partner for your beach libation of choice. True Pint's TempShield technology guarantees that your beverage stays cold for the duration. They are also stackable and durable so that they don't get smashed. Sorry red solo cup, the next beach happy hour we'll be drinking from this perfect pint.
Coleman Rugged A/T 55 qt. cooler ($89.99): With rugged 8-inch oversized wheels and a bungee tie down system sand transportation is easy. You won't lose any of those 84 beers that this cooler holds. It's "Have a Seat" lid allows you to sit down while keeping those beers cold in 90 degree temps for up to five days.
Mountainsmith Deluxe Cooler Cube ($49.95): The Cooler Cube is lightweight and easy to carry and has a surprising amount of space for a handheld cooler. However, the best part of this cooler is the drop-down beverage tray and the attached bottle opener making it your own personal mini-tiki bar.
Outdoor Technology Big Turtle Shell ($199): The Big Turtle Shell delivers an unrivaled, wireless audio experience. This speaker connects to and can charge your smartphone or tablet while providing the listener with 110 decibels of beautiful audio at up to 32 feet. It's also waterproof, shockproof and sand proof making it the perfect audio companion for the beach.
Vapur Incognito Flask ($6.99): This is not your grandfather's flask by any stretch of the imagination. Made with flexible material, this flask is lightweight and not bulky like old school flasks so it's easier to conceal in say... your board shorts. That alone makes it the perfect beach traveling companion for your spirit of choice.
Shark Leash by Modom ($180): This collaboration between MODOM Surf and Sharkbanz is a must have for any surfer. The interchangeable cuff attaches to any cord and Sharkbanz magnetic shark deterring technology is integrated into the band so you can surf all the big waves you want without worrying about what is swimming down below.
Helix Backcountry ($34.99): The Helix Backcountry lamp is compact, lightweight,and easy to travel with. The swipe control technology offers dimmable Maxbright LED bulbs and the expanding globe and legs makes for a powerful little lamp that can illuminate your night time beach experience for up to 60 hours.
GCI Outdoor Big Surf with Slide Table ($60): The Big Surf is a portable, comfortable chair and more. It folds flat for easy storage, has a Smart-carry shoulder strap for hands free transport and offers four comfortable sitting positions. The Big Surf's slide out table will have you sipping cocktails with ease while relaxing in this beach chair.
All Good Sunscreen Butter ($9.99): A day on the beach requires sunscreen that works. Sunscreen Butter by All Good will do just that. This product is all organic and offers spf up to 50 +. It is also waterproof, coral reef proof and goes on as smooth as butter.
HD Tuff Box ($9-$17): This heavy-duty box comes in multiple sizes. It is sand-proof and waterproof, which are two musts for the beach. Its shatterproof lid is durable as they come and the internal rubberized bumper system will prevent your valuables from getting broken while keeping them sealed off from the elements.


text:
Warp of linen, ground of red wool, design of two mounted archers or hunters (?) and four dogs in the lower half of the roundel, in light and dark brown, yellow, and green wool and natural-colored linen, ground of border of dark brown; design shows Byzantine influence.
Credit Line
Denman Waldo Ross Collection
Egyptian (Coptic), Early Islamic, 7th–9th century A.D.
Accession Number
Medium or Technique
Linen and wool tapestry


text:
Based on Dynamic Programming
- It is a graph analysis algorithm for finding shortest paths in a weighted graph with positive or negative edge(but without negative cycle)(shortest path between all pairs)
- The single execution of the algorithm will find the lengths(summed weights) of the shortest paths between all pairs of vertices. though it does not return details of the themselves.
- Also used for finding transitive closure
Algorithm details
Consider a graph G with vertices V numbered 1 through N. Further consider a function shortestPath(i,j,k) that return the shortest possible path from i to j using vertices only from the set {1,2,3,..,k} as intermediate point along way.
shortestPath(i,j,k) : returns shortest path from i to j using vertices from the set {1,2,..,k}
Goal: our goal is to find the shortest path from i to j using only vertices from the set {1,2,..,k,k+1}
Observation I:
for each of these pair of vertices, the true shortest path could be either
- a path that only uses vertices from the set {1,..,k}
- a path that goes from i to k+1 and then from k+1 to j
Observation II:
we know the best path from i to j that only uses vertices {1,..,k} is defined by shortestPath(i,j,k) and it is clear that if there were a better path from i to k+1 to j, then the length of this path would be concatenation of the shortest path from i to k+1 using vertices in {1,…,k} and the shortest path from k+1 to j (again, using vertices in {1,…,k})
shortestPath(i,j,0) = w(i,j)
where w(i,j) is weight of vertex from i to j.
and recursive case is
shortestPath(i,j,k) = min(shortestPath(i,j,k-1), shortestPath(i,k,k-1)+shortestPath(k,j,k-1))


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The Ways To Attempt In Declaring PPI Claims
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The Ways To Attempt In Declaring PPI Claims
Sat Aug 13, 2011 12:59 pm
Have you got a mis sold PPI or perhaps do you own a Payment Protection Insurance? Were you aware that you can also make PPI claims should you have a mis sold PPI? This article consists of ways to identify whether you've mis sold plan or not. This even further talks about the purpose of a PPI and how to confirm techniques for claiming PPI refunds.
PPI can be described as valid product that may be supposed to protect the loan of a client. If perhaps he may struggle to pay for their commitments, PPI will handle his payments. This policy is made to make certain that the company which presented the loan can easily still receive money. A plan usually pays within five years. Occasionally, the borrower has already been done paying for their loan and its interest fees, nevertheless PPI however proceeds gathering payments from policyholders. It is on the list of handful of logic behind why individuals have been advocating to produce a PPI claim. Depending on these conditions, an insurance policy holder can function processes to reclaim PPI.
You should know that we now have different tips on how you can have a mis sold PPI, one is that it was initially sold to you without having been advised about its use and ways in which long you might need to pay for it. Another is the contemplation on your capacity to pay, your age and your willingness to acquire the insurance plan. When you fall directly into these kinds of details, then you have a mis sold PPI and the only route to get the refunds is to apply for payment protection insurance claims.
Which are the causes of mis sold PPI? This is really the normally next common question. common query. Its possible you have mis sold PPI you did not bother to find out about the requisites, you could possibly were extremely anxious about the release of your loan. Another instrumental the answer to this is the bank or insurance policy providers that seek the services of brokers to complete the policy marketing for them. Consequently, these types of brokers tend to be wanting to earn income by exercising the key reason for having a PPI. If this happens, greater purpose you possess to make a PPI claim.
To ensure you're going to get your PPI compensation, seek the services of a law firm to do all the paperwork needed and court actions for you. He will support your letter to the loan provider. But, if ever the bank refuses to grant your claim, see to it that your particular case shall be brought to the Financial Ombudsman's desk. They are willing to re-consider your case and will assure that you'll be granted of your PPI claims.
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...FEATURS FROM Karenderia order taking app 2.5 TO 2.1, KEEPING THE CHANGES MADE TO 2.1 in the .docx document that I send, there are all the details script used: Karenderia - for this work focus on Karenderia -Order Taking App [login to view URL] time: maximum 4 days, if in 2 days, it would be exceptional
I need a Logo for my startup, a sport photography agency, called FinisherFoto. We cover Running, Bike and triathlon events.
Hello, I'm looking for a Japanese speaker of high fluency to help me correspond with a Japanese business through email by sending a few inquiries. Skills required are Japanese fluency, English fluency, and email.
We are reserarchers and industry partners that need a strong and clear logo for a competitive EU H2020 project proposal with the title "AQUAnOMICs". It is about new DNA-based technologies ('OMICs') for ecological assessment in water (AQUA), i.e. of water quality in rivers, lakes and the ocean. The logo should be simple and clear, include the
We need 200 No`s photos in total optimised to be used for Amazon as current size and background is not accepted. See a sample of photos as they currently are. Will need resizing, refining and background editing, renaming etc. See all requirements details bellow: "Image size: Images should be at least 1000 pixels in either width or height. Amazon recommends
This company books golf vacations for golfers.
I need three call to action buttons designed They must match the col...[login to view URL] The button sizes are 4 inches x 4 inches (each) and can be JPG The call to action titles will be: REGISTER FOR TOCA SOCCER TOTS PROGRAM Soccer program for 2-5 year olds LEARN MORE Learn More about our studio and training programs
Hello, I'm looking for freelance work. I'm specifically looking for someone who is talented in the ANIME art style department and has moderate experience with work. It would also be a plus to be familiar with programs like Adobe Flash but its not entirely necessary. I am typically looking for simple still images for my projects so nothing difficult
hello this is a well coded contact form with a page that you log in to generate numbers you need valid id to send it is made for a festival if you gonna work for me do not change design sql system etc install it, on your wamp servet to test it. and what modification i need is that when you get the right id from the festival crew this is on then it will
I need a Logo for my startup, a sport photography agency, called FinisherFoto. We cover Running, Bike and triathlon events.
Needs to hire 5 Freelancers Looking for 3 -5 copywriters (English language) to write blog articles and online game reviews. No rewriter, no translation. You will be provided with the text structure but we still expect you to do some research on the topic because we want our texts to be useful for our readers. Before hiring you will get test assignment
I started a project for helping the inventors and the people they need to build their ideas or prototypes, they can enter the place and use every machine like ( 3D printers, laser cutter, electronics ) by paying membership fees. or meet our team to discuss the idea and we will build it for them. the project name is ( ITOR ) the slogan is ( IDEA TO
...companies and work together Need SEO for 4 website - Once again 3 companies are sister companies and one is duplicate website of another. These will need SEO edits to header and descriptions and such, also will need link building. Articles can be discussed as a per article for $ basis. Adwords will be established for couple website and will require on
Making facade technical drawings (panels unfolded, pressure plate, cover cap, transom, mullions, louvers s and clits angle for machining. And cutting list as per giving work orders.
Hi, I have Gamobjects (see Picture below) I want to export into a 3D-PDF on runti...to export into a 3D-PDF on runtime. The Colours should be preserved. The resulting PDF should contain additional text and tables as well, but your job is only to leave room for the possibility of adding these. If that can't be done: Export as U3D or PRC is also fine
I am looking for a story teller and go-to-market product marketer who can take my guidelines and bring it to life. This candidate must be extremely creative, process orientated, and have a knack for mobile product positioning. More instructions will be provided later. I need someone with a lot of experience in mobile growth and go to market particularly
Hi, We're looking for a logo design for a web hosting company. Please do not use a generic cloud icon.. See examples of ones below we like. [login to view URL] [login to view URL] [login to view URL]
SEO Audit for another client
I would like to have a PDF for my clients regarding "Balancing Infertility". Central to this theme is: Maintaining a Sense of Self, Strengthening Personal and Intimate Relationships, Physical and Emotional Wellness, Learning about Fertility and Reproductive Health, Spirituality, Decreasing Stress, and Building Hope. I would love the PDF's to be simplistic
We need logo for our Business with name Robotik Metal. We do powder coating services. Logo must be simple but in a couple of colors


text: A lovely robot from the Big Carrot's planet is condemned to find a heart in a far planet in order to marry Princess Mimi. He arrives on Earth and meets Monica's Gang, the most famous characters from Brazilian cartoons. The gang decides to help the robot, in a journey through the universe.


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Poundland Jane Asher bakerys goods for £1/ some 2 for £1 such as cake decorations
Found 12th Sep 2014
Poundland now sell Jane Asher bakery goods various things from cake cases to rolling pins to mini scales. I thought the 2 tubes of cake decorations for £1 were good value as other branded ones are around £1.30 each in main supermarkets.
Community Updates


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The federal indigenous affairs minister admits he must do more to raise issues with the states and territories after revelations of abuse of young boys in Northern Territory detention.
But Nigel Scullion insists he didn't act on briefings about abuse at the Don Dale detention centre before graphic footage aired on ABC's Four Corners program because he was convinced the Northern Territory government was dealing with it.
The department of prime minister and cabinet also believed the NT government was addressing the issues.
The territory had adopted 15 of 16 recommendations made by a review of NT detention - commissioned by its government and released in February 2015 - and had signed off on an August 2015 children's commissioner report.
"Everything we had seen... indicated to us that they had taken the two reports seriously," associate secretary Andrew Tongue told a Senate committee on Friday.
Prime Minister Malcolm Turnbull launched a royal commission after the ABC aired footage in July of boys being tear gassed and placed in spit hoods.
Senator Scullion admits the program showed a culture of cover up and brutality at Don Dale of which he was previously unaware.
"It was shocking," he said.
"It has given us all a shake."
The minister used his opening statement to "set the record straight" about what he knew about Don Dale and the boys held there.
He confirmed his office was given a parliamentary question time briefing on Don Dale in October last year and the issue had been raised in another meeting.
But he said none of the briefings or public reports on the alleged mistreatment were as graphic as the footage aired on the ABC.
"The footage shown during that program was deeply disturbing a way no written report can fully convey," he said.
Labor senator Jenny McAllister took issue with that, pointing to reports in October that described young boys being told to eat bird faeces and forced to fight each other.
In an at-times heated exchange, Senator McAllister accused the minister of making contradictory statements - including about who asked for the briefing in October.
She also questioned why Senator Scullion had told media on the day after the Four Corners report that he had not received a brief on the issue.
A formal brief was different to a briefing, he said, because the former had to be signed off.
"I had no briefings that would lead me to suspect that those matters that we'd seen... were occurring," he said.
He said allegations he had misled the public were "absolute garbage".
NT media have been reporting abuse at the Don Dale centre since 2014 but it wasn't until the July ABC report with graphic footage that it went national.
But the minister said no one from Labor had asked him a question about the abuse in parliament.
Senator Scullion has written to all state and territory ministers to seek assurances about detention practices and insists he's taking a more proactive approach to briefings on indigenous issues.
The minister has also offered funding to states that do not have a mandatory custody notification service - a legal service hotline for indigenous Australians taken to prison.


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These honors are a testament to the strength of our physician team and the high level of standards we have instilled for patient care.
Marina del Rey, Calif. (PRWEB) January 06, 2016
DISC Sports & Spine Center ("DISC") today announced that 13 of its physicians have been named top doctors in Southern California by the 2016 Southern California Super Doctors®. With the number of doctors receiving this honor limited to approximately five percent of the region's active physicians, DISC's stellar showing represents the center's ongoing commitment to excellence in patient care.
For 2016, DISC's physicians on the Southern California Super Doctors list include neurological spine surgeons Robert S. Bray, Jr., Richard B. Kim and Amir Vokshoor; orthopedic spine surgeons Sanjay K. Khurana, Hooman M. Melamed and Hamid Mir; orthopedic surgeons Gary Brazina, Frederic G. Nicola, John J. Regan and Andrew Yun; pain management experts Glenn M. Lipton and Michael Port; and physical medicine & rehabilitation expert Katrina M. Vlachos. Additionally, physical medicine & rehabilitation expert Sarah Miller was included in the 2015 Southern California Rising Stars list.
Since 2005, MSP Communications has published Super Doctors lists across the country in newspapers, inserts and magazine special sections devoted to Super Doctors. Honorees are also found online at http://www.superdoctors.com, where selected doctors can be searched by name, medical specialty and location.
Each year, MSP Communications undertakes a rigorous multi-phase selection process that includes a survey of doctors, independent evaluation of candidates by the research staff, a peer review of candidates by practice area, and a good-standing and disciplinary check. As a part of this evaluation, physicians are asked to consider the following question: "If you needed medical care in one of the following practice areas, which doctor would you choose?"
"We are truly honored to have so many DISC doctors chosen for this year's Southern California Super Doctors list," said Dr. Robert S. Bray, Jr., DISC's founder and one of neurological spine surgeons included by Super Doctors. "These honors are a testament to the strength of our physician team and the high level of standards we have instilled for patient care."
Beyond attracting and maintaining a staff of highly rated physicians, DISC continues to transform patient care in the outpatient setting through its preferred partnership with Surgical Care Affiliates (SCA), a national leader in the development and implementation of strategies that improve the quality and efficiency of surgery services.
About DISC Sports & Spine Center
DISC Sports & Spine Center (DISC) is California's premier medical group providing the full scope of spinal care, orthopedics, pain management and conservative treatments. DISC has set a new standard for high-acuity, minimally invasive spine surgery and arthroscopy in an outpatient setting, both safely and on a more cost-effective basis. In partnership with Surgical Care Affiliates (SCA), one of the nation's leading surgical care companies, DISC operates state-of-the-art outpatient surgery centers in Marina Del Rey and Newport Beach. Both centers are accredited by the AAAHC, have a zero MRSA infection rate and are conveniently located next to major freeways and airports. DISC, which accepts most major insurance plans, is also the official medical services provider for Red Bull and a proud partner of the LA Kings. For more information, contact 866-481-DISC, or visit http://discmdgroup.com.


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Duffy calls for apology over offensive tweet and for its immediate removal
Published: 26 March, 2018
Speaking following a tweet from UKIP Councillor David Jones Sinn Féin Councillor Paul Duffy said:
"UKIP Councillor David Jones has mocked those 14 Bloody Sunday victims massacred by British Army paratroopers as they attended a Civil Rights march in Derry.
"Councillor Jones should reflect on the hurt and pain already suffered by the families of those murdered on Bloody Sunday.
The tweet should be deleted and Councillor Jones should issue an apology immediately."
Latest News
Copyright 2018 Sinn Féin. Contact


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Back pain has become a common problem among the present days, irrespective of age and gender. The lower back pain is usually considered as back pain. The range of the problem differs from person to person. Severe pain in lower back causes difficulty in walking and standing. For few of the people, the pain remains achy continuously for a long time. Mild pain with discomfort at lower back is also considered as back pain.
Most of the times, people use the general medication like pain relievers, application of heat and taking rest for some time. Yet, many people get the back pain recurrently which is rather ignored and treated with general medication. This may lead to few other problems like sciatica. Thus, one must recognize the level of pain and the reasons of the pain. As per the necessity, consulting the expert is highly suggested.
There are several reasons for the cause of the pain. Any of these reasons may cause the ache and suffer the patient.
1. Muscle strain: Due to heavy work or bending several times may strain the muscle and cause the pain acutely. Some time the soreness can also be noticed. General medication and rest are often suggested advices for the back pain that caused due to muscle strain.
2. Lifting heavy objects: Lifting heavy objects often causes muscle strain and lead to the back pain. But some of the times, it may also lead to the fractures. Confirming with the physician is appreciated if the pain is very severe.
3. Sudden movements: While travelling on two-wheeler or four-wheeler, while walking or while working; few of the movements suddenly cause the strain and leads to the back pain. Few of the exercises which are not suggestible, also cause the back pain.
4. Low calcium levels: Lower calcium levels cause not only the back pain but also among several parts of the body. Even the mild muscle strain or sudden movements may lead to fractures when the calcium levels are low. Taking healthy food which provide calcium and taking calcium supplements with the doctor's suggestion are necessary.
5. Improper postures: Many people don't care the way of sitting, standing or walking. In long run, the improper postures in sitting, standing and walking may lead to several difficulties and back pain is one of those difficulties. Often many employees sit for a long time resting the back for support. In long run this kind of sitting postures without body movements for a long gap, become a cause for the back pain.
6. Accidents: Severe attack on the spinal cord due to any of the reasons like accidents also leaves back pain. Often medication and physical exercises, for a long run help to get recovered.
7. Facet joint osteoarthritis: This type of arthritis develops in the aged people. The problem may lead to other problems like sciatica. The pain leads to stiffness at lower back which can be noticed more during mornings and evenings.
8. Compression fracture: This type of fracture is majorly noticed among men and women over 50 years of age, particularly those who are suffering from osteoporosis (a bone disease). Even minimum strain may cause fracture on spinal cord. Loss of height, less back bone flexibility and pain during walking or standing are few of the common symptoms of compression fracture.
9. Lumber degenerative disc or Isthmic/degenerative spondylolisthesis: Lumbar degenerative disc, a disease which can be noticed among men or women around 20 to 30 years of age, causes severe lower back pain and may lead to other complications. Isthmic spondylolisthesis, is noticed as slip of the disc that causes pressure on roots of the nerves also cause acute pain. Degenerative spondylolisthesis is observed more among the older people. Back pain one of the symptoms of it.
10. Other reasons like infection or tumor: Apart from the above reasons, there are several other reasons which may not be common. Infections on the back bone, tumor or spine etc may also cause the back pain.


text:
This is a video of Girl Kitty. Mom has to take Khaki to the vet this morning since he was gone for four days and has a big hard lump on his head and something on the side of his cheek.
We will update a little later.
Well Khaki is home from the vet, the poor thing. He is now hiding UTB. He had to kind to have surgery on his head to open all the abscesses. They had to wrap his head to come home.As you can see he didn't want anyone to see him like this. I took the bandage off and that isn't much better.
I kind of wish they hadn't done so much cutting but too late now. I guess it all needed to drain.
We sure hope everyone has a great day.


text:
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We can't get to the phone right now. If you leave your name and number we'll be sure to get back to you. BEEP
For booking information contact Idiots Without Credibility directly here. We'll do most anything if you ask us.
If you are interested in being a guest on our Podcast or writing for the website contact us directly here with "IWC Guest" in the subject line.


text:
Product Code: SURVDVD
Now: $19.95
You Save: $5.00!!
Our SURVIVOR DVD is a female Self Defense and awareness course. Hands on moves to fend off the most common attacks against females along with tips, tactics and awareness training.
Learn to defend and avoid against unwanted assault or sexual attack. From self defense tips for everything from dating and living alone to traveling and what to look out for. This course is taught in everyday and easy to understand language.
You will lean
~Strikes w/ your Hands, Elbows, Knees, Feet...and your Brain
~Defense against: Chokes, wrist grabs, bear hugs, attacks from behind, being thrown to the ground, and defenses while seated
~Info & Stats on most common female attacks
~Using Improvised weapons and where to find them
proceed to checkout
continue shopping


text:
http://www.pcworld.com/businesscenter/article/150021/georgia_cyberwar_overblown.html By Andreas M. Antonopoulos Network World August 19, 2008 Last week Russian tanks rolled into South Ossetia while Russian bombers were taking out critical communications infrastructure. But even before the first tank rolled across the disputed borders, another war was brewing in cyberspace. Armies of hackers started attacking critical cyberinfrastructure in Georgia. A counter-offense of Georgia hackers fought back to control major routing exchanges. Then a disturbing escalation: Georgian hackers were able to take control of Russian strategic launch capabilities. The Russian defense AI was defeated and forced to begin the launch sequence of ICBMs toward strategic targets everywhere. At the last moment, a Russian teenager with top-secret network access gained over an open Wi-Fi in his high-school network was able to persuade the Russian AI to back off by showing it the futility of war through a game of tic-tac-toe. Oh, wait a second -- that's a movie plot! None of this actually happened For all the reports of cyberwar between opposing arming of cyberwarriors, you'd think that a big part of the war was being fought in cyberspace. A few instances of denial of service (DoS) were being amplified by the media into a cyberwar. I got e-mails and calls from journalists asking me about the implications of cyberwarfare, the vulnerability of U.S. infrastructure and the potential for electronic Pearl Harbor. What a load of [redacted:TOPSECRET]! [...] __________________________________________________ Register now for HITBSecConf2008 - Malaysia! With a new triple-track conference featuring 4 keynote speakers and over 35 international experts, this is the largest network security event in Asia and the Middle East! http://conference.hackinthebox.org/hitbsecconf2008kl/Received on Wed Aug 20 2008 - 04:36:59 PDT
This archive was generated by hypermail 2.2.0 : Wed Aug 20 2008 - 04:41:45 PDT


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Hi everyone!!!
Sorry for being away for a really long time but I had no choice.
I was out of internet coverage for some time now (:
Anyways there is a saying that everything has to come to an end..
So does the life in Bramall Court, Sheffield.
After spending the entire Summer in Bramall Court, we do have feelings for it..
Both people and place.
But sadly, on this day *refer to the date below* most of us will be leaving this place to explore Europe.
*Yes, almost everyone will be on their eurotrip*
So lets start the blog post!!
1st rule before leaving an accomodation..
..you have to pack your things.
Next, you will think about the days you spent in that very room..
..and try not to cry.
Since it would be the last day for the whole course to be in Bramall Court *where we stayed*
we had decided to organise a farewell party..
Jobs and responsibilities were delegated 6 hours before the party and everyone had a role to play.
We bought food,
We cooked some,
We prepared the tables etc..
Of course..we took photos too!!
*The table setting crew*
A few macho men carried the dining tables from our flats into the open space.
Some of us set up the table..
Nonetheless, we did it together..
*Setting up the tables together-gather*
Representatives from different flats cooked..
*The guy team from Flat 27 & 16*
*It involves food tasting too!!*
When everyone is ready, we start to feast!!!
*Last memories of the togetherness of AEM*
4 years of friendship..
..is worth nothing when it comes to food!!
*Snatch SNatcH SNATCH!!!!!*
Oh come'on!!!
*Janganlah makan sendiri~*
Show some love~~!!
*Feeding is caring*
Nothing beats having a good meal together..
..it feels like family.
While some are busy eating..
..others were busy taking photos..
As for me, I like posing with FOOD..
*The one on the left is not candid..I did that on purpose..*
Some have HUGE mouth..
*He finished a slice of pizza with 1 bite*
..others can't follow..
*Sunkel with just another regular sized mouth*
We help each other out..
*Sunkel helping LYR with drinks*
*Me helping Winnie with pizza*
Some uses food as props..
*Mei Mun*
..others prefer using drinks..
We love snatching food..
..and laughing out loud..
When its time for the 1st batch to leave..
The TONG HANG tour group members.
Kek, Tim, Charles, Mong Jia, Yuet Hwa
There will definitely be hugs..
..and tears..
Everyone said their goodbyes..
..and gave their salutes..
And there they go, on their adventure to Europe..
Although it was a simple farewell party,
but the company is what matters most right?
So what do we think about this party??
Everyone said, "GREAT!!!!!!"
I miss them...
Oh for more photos in this album, click here!!!
Sunday, 11 October 2009
The day they went away..
Hi everyone!!!
Frosted on the imprints of an ice slate by Leslie at 02:55


text: This may seem like a strange analogy, but tooth recontouring is almost like sculpting. People's teeth wear over time or sometimes have natural patterns of unevenness or slight overlapping that can be unattractive and could house bacteria. With tooth recontouring, Dr. Antalis artfully reshapes your teeth and leaves you with a beautiful and healthy smile.


text:
On 31 May 2017 Ant Kids Bali held hygiene counseling in Gilimanuk and Banyuwedang with the topic of Clean and Healthy Living Pattern presented by Samudra Safera. In addition, we provide sex education counseling for Tojan (7 June 2017) and Sanur (May 30, 2017) delivered by PKBI - KISARA community.
The event went smoothly, as many as about 100 children of Ant Charity attended the counseling with the help of volunteers. In this counseling, they were taught how to keep themselves safe. The children looked happy when they were taught by Samudra and volunteers from PKBI - KISARA community and now they've known how to keep themselves safe and healthy.
Hi my samoedra I am the Head of Health Department Ant Charity. I have visited the life centers in Bali to provide early sex education. Indeed this was something that was not common but having seen the high level of child sexual abuse, I felt responsible for prevention. One of the preventive measures was to have early sex education. I thank Susan as Repsentative Ant Charity in Bali who has arranged the event well. Thank you PKBI - KISARA community for providing a good and very interesting counseling.
With songs and also pictures, the children and parents who early were so taboo with reproductive health, at the end become more open minded, at least they know better how to take care of themselves. In addition to that which made me touched, glad, happy, and grateful was the program of feeding Ant Charity has remarkably developed. All the children are now healthy and there was no indication of having malnutrition. Although it is not maximal yet but the better changes are there and real!
They are also now aware to maintain cleanliness. There were only a few children whose nails were rather dirty and long but from hundreds of children only a few children who had to nail clipped in place.
Thanks for the volunteers and donors. You are the real angesl! Without your prayers and material supports that you have given, it would be hard for Ant Charity to be there and continue to exist until this moment! Because of you, the future of these children become bright... because you have brought the light to the kids !!!
Beyond blessed,
Samoedra Safera
Head of Health Department


text:
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Experience the Next Generation of Comfort from Performance Scrubs!
PerformanceScrubs.com Announces Partnership with the University of North Alabama College of Nursing
Florence, Alabama ? PerformanceScrubs.com, a Performance HealthCare Products company, today announced a partnership with the University of North Alabama (UNA) College of Nursing to provide them with another option for nursing apparel for their students.
Through this cooperative effort, the University of North Alabama?s College of Nursing will work closely with PerformanceScrubs.com to provide innovative nursing uniforms to the faculty and the students attending the nursing program.
"We are excited about the possibility of the benefits to be achieved through partnering with PerformanceScrubs.com. The product they have developed represents forward thinking for our student nursing and faculty apparel for its professional look, comfort, ease of care and flexibility of design," states Dr. Birdie Bailey, Dean of the College of Nursing.
"We could not be more excited about this new relationship with UNA, especially with the recent announcement of our new manufacturing facility in Florence, Alabama. Our scrubs are American-Made, right here in Alabama, so our partnership with UNA is a perfect fit for our company," says J. Kirby Best, CEO, PerformanceScrubs.com.
PerformanceScrubs.com are 100% American-Made using a high-tech moisture wicking material. The scrubs are wrinkle resistant, stain resistant, and fade resistant, and will keep that new look through dozens of washings. You custom design your own scrubs choosing color, style, pocket positions, size, and trim. You can mix and match colors, trims and ribbons to create literally thousands of looks - 2.4 million to be exact!
About Performance HealthCare Products, Inc.
Based in Nashville, TN, Performance HealthCare Products, Inc. specializes in designing, manufacturing and distributing technologically advanced healthcare scrubs/uniforms and sleepwear created to provide both comfort and function. Founded by CEO J. Kirby Best, PHCP maintains a manufacturing facility in Florence, Alabama and utilizes only American made materials in their products. Companies include: PerformanceScrubs.com, PerformanceSleepwear.com, PerformanceSoaring.com, Performance Systems USA and OnPoint Manufacturing.
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