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LearningDevelopment@ForthValleyCollege's curator insight, October 8, 10:12 AM
Now that you have the iOS 8 upgrade checklist, here are some new features of iOS 8 that we thought you may like.
Kathleen McClaskey's curator insight, September 18, 4:55 PM
Don't miss this incredible resource that Diana has put together for learners that struggle in reading, writing and math. This is a must resource for every school on the planet!
Patricia Schachtner's curator insight, March 25, 2:18 PM
This video really helped to expand my understanding of the importance of AT in schools.
Donna Farren's curator insight, August 12, 2:06 PM
Fantastic information here - really a topic everyone in training should be learning more about.
Kathleen McClaskey's curator insight, April 10, 2:31 PM
Don't miss this reader that can make a difference in math!


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James Bond 007 Retrospective: Casino Royale (2006)
James Bond 007 Retrospective: Casino Royale (2006)
Casino Royale (2006)
Directed by: Martin Campbell
Starring Daniel Craig, Eva Green, Mads Mikkelsen, Jeffrey Wright
Bond goes back to basics as we discover his first mission that earned him his 00 status. The super spy must go head to head with international terrorist financier Le Chiffre in a tense game of high stakes Texas Hold'Em poker at Casino Royale, Montenegro.
No, not the mish-mash that was the 1967 multi-directorial disaster, but of course the epic reboot that reinvigorated the long running, much loved spy franchise. Layer Cake and The Girl With The Dragon Tattoo actor Daniel Craig was eventually chosen to slip into the tux as the 6th actor to play the secret agent and it's through these Bond films that Craig was able to flex his acting chops, demonstrating to audiences around the world that he could handle those tough action scenes aswell as providing a magnetic screen resonance. He has also enjoyed considerable on screen success away from his stint as Bond, including a skit in 2012's London Olympic opening ceremony sending up his 007 persona and appearing to parachute out of a helicopter with the Queen!
This rebooting of the series also benefits hugely from Martin Campbell's return to the director's chair, who after working wonders in relaunching the series with Pierce Brosnan's debut as Bond, Campbell does it again with Casino Royale. Danish star Mads Mikkelsen is incredibly oily as Fleming's central villain Le Chiffre whose physical defects may give Bond the upper hand at the poker table. Caterina Murino sizzles as love interest Solange but it's Eva Green as the multi layered Vesper Lynd who delivers the most appealing performance in the film, portraying a character who beneath the tough exterior is almost as fragile as 007 himself.
Bond will return in…. Quantum of Solace.
Film: ***** Extras: ****

subset: commoncrawl


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Here's the vote on the health care bill today
One oddity: Sen. Jim Bunning, R-Ky., skipped the vote – the only senator to do so. Our Kentucky politics reporter, Amanda VanBenschoten reports that, according to a spokesman, Bunning had "family commitments" and was at his Southgate home during the vote.
In a statement issued Wednesday, Bunning called the bill "a two and a half trillion dollar scam that will bury future generations of Americans under mountains of debt and puts Members of Congress and Washington bureaucrats in charge of your health care."
Sen. Sherrod Brown voted for it. Sens. George Voinovich and Republican leader Mitch McConnell voted against it.
Here's Voinovich's statement:
"Americans watching the health care debate in Washington as they prepare to celebrate the birth of Jesus Christ with their families know that today's action will have far-reaching consequences on their lives and our entire economy. That is why they, like I, oppose this bill. It is not reform and it is not what the American people want.
"The two-trillion dollar spending bill rushed through by the Democrats cuts Medicare, raises taxes, increases premiums for health insurance, places additional burdens on states and threatens the health choices that millions currently enjoy. At a time when Ohio's unemployment rate is at 10.6 percent, new health care legislation should first do no harm to the economy.
"Instead, the Democrats are raising taxes by more than half-a-trillion dollars. Paying for health care reform by placing these additional financial burdens on American families and small businesses will further impede our ability to compete in the global marketplace and, ultimately, our economic recovery.
"This bill is full of budget gimmicks to mask its true cost of nearly $2.3 trillion over 10 years when fully implemented. The bill will cut Medicare by $467 billion, which will impact health coverage for our seniors. I am particularly troubled by these cuts as the current Medicare program is already on shaky footing and expected to be insolvent by 2017, with $37 trillion in unfunded liabilities. I do not understand how my colleagues think we can do more when we cannot even afford what we have now. Additionally, I cannot support this bill because it directly and indirectly allows taxpayer dollars to be used to pay for abortions.
"Something as enormous and complex as health care reform should have been accomplished through bipartisanship and complete transparency. I pray, along with many of my constituents, that the American people will take time over the holidays to read the final Senate and House health reform bills and continue to let their voices be heard as the chambers prepare to reconcile their differences and complete work on final health care legislation. That will be our last opportunity to pull the emergency brake on this fiscal train-wreck."
Sen. Voinovich voted against H.R. 3590 for several reasons, including:
· The bill cuts $467 billion from Medicare to fund a new government program, even though Medicare will go bankrupt in 2017. Any savings achieved should be reinvested in these programs to ensure their future viability;
· The bill does not include a permanent fix to the Sustainable Growth Rate (SGR) formula that reimburses doctors under Medicare. In fact it ignores the fact that we must fix the flawed formula all together. It is unrealistic to assume physicians would receive a 23-percent decrease in reimbursement levels beginning in 2011 with future reductions;
· The bill reduces payments to Medicare Advantage (MA) plans by $120 billion. There are approximately 500,000 Ohioans in MA programs, and in January 2010, Medicare-eligible Ohio Public Employee Retirees (OPERS) will be enrolled in Humana's Medicare Advantage plan. CBO has said these seniors could see their added benefits (vision, dental) eliminated;
· The bill has no meaningful medical liability reform. CBO estimated that enactment of medical liability reform would reduce health care costs by $54 billion over 10 years;
· The bill would expand Medicaid even though physicians increasingly refuse to see Medicaid patients now and states would bear $25 billion in new costs. States are already having trouble meeting their obligations under the Medicaid program and that is with a temporary $87 billion increase in the federal stimulus legislation; and
· The bill does not do enough to protect federal funding from being used to cover abortions.
Here's Brown's statement:
"American families know first-hand that health insurance premiums have been skyrocketing," Brown said. "This bill will lower costs for middle class families with insurance, while providing help to 31 million Americans who lack it. And insurers will have to play by a new set of rules, including an immediate ban on pre-existing condition exclusions for children.
"The bill also invests in small businesses – providing an immediate tax credit to help employers cover their workers. If we're going to rebuild our economy, we need to ensure that small businesses – which create more than 64 percent of our nation's jobs – are not crushed by exploding health costs.
"Seniors on Medicare will see their prescription drug costs cut in half and, for the first time, will have access to free annual check-ups and screenings. The bill, which has been endorsed by AARP, also extends Medicare's solvency by nearly a decade.
"This bill means Americans will have affordable insurance options if they change or lose their jobs. It means an end to insurance industry practices that cut off access to medically-necessary care or discriminate against women or individuals with pre-existing medical conditions. It means insurance companies will have to spend premium dollars on medical care – rather than on lavish sales trips and exorbitant CEO salaries – or else give rebates to consumers.
"When it comes to health care, the cost of inaction is simply too high. More than 390 Ohioans lose their health insurance every day. Small businesses and the self-employed can pay double or triple what large businesses pay for coverage. By 2007, 62% of bankruptcies were due to medical costs. And forty-five thousand Americans die each year because they are uninsured and can't get the care they need.
"American families can't have economic security if they're one hospital visit away from financial ruin. And American businesses can't attract the brightest minds or compete globally if they're saddled with unaffordable health insurance rates. American families and businesses deserve more affordable and dependable health insurance, and this morning's vote moves us one step closer to that goal.
"The bill we are considering is not perfect by any means, and there are plenty of areas where it falls short of what I would like to accomplish. But there are about 31 million reasons to support it. "
Here's McConnell's floor speech:
"It's early. I'll be brief. The most obvious problem with the bill before us is that it doesn't do what it was supposed to.
"The one test of success for any bill was whether it would lower costs. This bill fails that test.
"It's also clear that even many of the people who support this bill with their votes don't like it.
"Otherwise, Democrat leaders wouldn't have had such a tough time rounding up votes.
"Otherwise, Democrat leaders wouldn't have had votes on it in the middle of the night, or at the crack of dawn, or over the weekend, or during a blizzard.
"Otherwise, they wouldn't be rushing it through Congress on Christmas Eve — the first time this body has had a vote the day before Christmas in more than a century.
"This debate was supposed to produce a bill that reformed health care in America.
"Instead, we're left with party line votes in the middle of the night, a couple of sweetheart deals to get it over the finish line, and a public that's outraged.
"A problem they were told would be fixed wasn't.
"I guarantee you the people who voted for this bill are going to get an earful when they finally get home for the first time since Thanksgiving.
"They know there is widespread opposition to this monstrosity.
"This fight isn't over. My colleagues and I will work to stop this bill from becoming law.
"That's the clear will of the American people — and we're going to continue to fight on their behalf.
Tags: Brown, health care, voinovich


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News Releases
RWJF News Releases
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RWJF News Releases
January 30, 2013 | News Release
RWJF Nurse Faculty Scholars Program Offers Exciting Opportunity for Future Nurse Leaders.
November 28, 2012 | News Release
A new study identifies the factors that best predict whether nurses will return to school to earn higher degrees.
September 19, 2012 | News Release
A statement in response to the joint announcement from community college and nursing organizations supporting academic progression for nursing students and graduates.
August 20, 2012 | News Release
Tri-Council for Nursing leads RWJF-Funded program, which will support 'Action Coalitions' in CA, HI, MA, MT, NM, NY, NC, TX and WA state.
June 19, 2012 | News Release
Scholarships, program support will aid second career nurses from groups underrepresented in nursing who are enrolled in accelerated degree programs.
August 27, 2012 | News Release
Highly competitive program is supporting research and leadership skills of promising junior nurse Faculty around the country.
August 9, 2012 | News Release
Evaluating Innovations in Nursing Education program awards grants to support research on doctoral education and production of faculty.
September 20, 2010 | News Release
Prestigious program is advancing the careers of some of the nation's most promising junior nurse faculty.
May 28, 2009 | News Release
Innovative public/private partnership launches at state legislative hearing.
January 9, 2008 | News Release
$28-Million Nurse Faculty Scholars program offers career development to promote ranks of junior faculty.


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GreatSchools Rating
Teacher quality
Principal leadership
Parent involvement
I also feel that the instability of an administration team has impacted my child. The bus has also been an unstable area of constant change and disruption. My child loves going to school and as a parent, I feel listened to when I have a concern. Overall, my child is receiving a well rounded education and we should be proud of our school!
Kratz has been a great school for us. I have never seen such a great group of teachers going out of their way to ensure our children are receiving the best education available. I have two areas of concern at Kratz: Administration - Our school in recent years has had a hard time in maintaining a principal and vice principal. I feel the children would prosper more if we had some stability in this area. I know normally this is out of Ritenour's control. The second area is classroom sizes. Overall I feel the teachers and staff give their all to making our childrens life a little bit better
I used to go to this school. It has exceptional teachers, great office staff, enriching extracurricular activities, and a below average school-PTO relationship.
Community ratings and reviews do not represent the views of GreatSchools nor does GreatSchools check their accuracy or verify the reviewers' identities. Use your discretion when evaluating these reviews.
The Community Rating is the school's average rating from its community members (e.g., parents, students, and school staff). The highest possible rating is five stars; the lowest is one star.
4301 Edmundson Rd
St. Louis, MO 63134
Phone: (314) 493-6360
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We now interrupt Farrah Abraham sex tape coverage for a look back at last night's Teen Mom 2, in which we pick up after Jenelle's latest blowout fight.
Meanwhile, Leah walks down the aisle with a special man at her side, Kailyn and Javi fast-track their own nuptials, and Chelsea is sick and "stressed."
Read all about it and more in THG's official Teen Mom 2 recap!
After the fight between Jenelle Evans and Gary Head, she obviously leans on that asshat Kieffer Delp for support. Minus 100 for never, ever learning.
As Jenelle recounts the violent altercation between herself and Gary, it's clear she wants nothing to do with him anymore ... well, at least for a few days.
She tells Tori that Gary ripped the ring off her finger and tried to strangle her with a bed sheet, which is probably blatantly untrue knowing her. Minus 100.


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In WMMA there seems to be a trend of stables coming together. Some fans know about the Four Horsewomen group – composed of Ronda Rousey, Shayna Baszler, Jessamyn Duke and Marina Shafir – that is a take on the professional wrestling Four Horsemen stable that dominated professional wrestling in the late '80s and early '90s.
Over the years there have been a who's who of wrestlers who held the four-finger salute. Some of them great, some not so much.
Keeping with the professional wrestling theme, I've decided to think of four female fighters who would also fit professional-related nicknames.
Note: This is purely for fun.


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Only certified TM teachers can provide instruction in the authentic Transcendental Meditation technique.
In the U.S., the certification of TM teachers is available exclusively from Maharishi Foundation USA, a federally-recognized 501(c)(3) non-profit educational organization. Certified TM teachers have successfully completed an intensive 5-month in-residence Teacher Training Course, and they maintain their certification through ongoing professional courses for TM teachers.
Valerie JanLois learned TM in 1974 when she was touring New England as a solo musician and with the Northern Lights Band. Music had always been her main focus, mostly because she felt real happiness only when she was singing. Learning TM was a revelation; she began to experience a rich fulfillment and joy in the smallest things and happiness became the norm rather than associated with just one activity.
Ten years passed and a desire to teach TM that had begun to germinate on that day in 1974 came to fruition when Valerie became a teacher of the Transcendental Meditation program. Valerie earned a doctorate at Maharishi University of Management and taught hundreds of people in New York before relocating to the Bay Area where she's been happily teaching TM for nearly 25 years.
"You could say teaching TM is my way of giving back but you know the old saying – 'The teacher gets more than the student' – and in the case of the TM teacher, this is profoundly true."
Margaret Ryle has been practicing the TM technique since 1973 and teaching since 1989. She taught for nearly a decade in California's famous Silicon Valley area where she was the director of the San Jose branch. She has lectured on the TM program to businesses, university classes, medical doctors, educators and the general public.
Margaret has several years of corporate communications experience at a Fortune 100 company and holds a master's degree in education from Maharishi University of Management. She is a certified teacher of the TM technique, teaching in Contra Costa County.
"There is no profession more fulfilling than being a teacher of the Transcendental Meditation technique."
Bob Dillon has been practicing the Transcendental Meditation technique since 1972 and teaching it since 1974. He has taught extensively in Thailand, Malaysia, Singapore, Indonesia and the U.S. Bob is a former IBM Field Engineer, former regional vice president of a group of life insurance companies, former national lecturer on Medicare compliance to the U.S. medical community and presently a multi-state licensed insurance professional specializing in IRA distribution, tax planning and charitable gifting. He is a certified teacher of the Transcendental Meditation program.
"I feel that teaching TM is the best thing I could ever do for another human being. It is such a simple process that transforms every area of life. It?s an immense privilege and humble honor to be part of the tradition of TM teachers."


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October 30, 2014
It's not what they do, but how old they are that makes them unique.
Samantha Sprole plays the flute, but that's not what makes this 15-year-old special. Samantha is in the P.E.G., program for exceptionally gifted students at Mary Baldwin College. She says high school was not challenging enough.
"I came her because I was dissatisfied with high school," said Sprole. "I wasn't enjoying it or having a good time. I didn't feel challenged and I found most of high school was all about the social aspect."
Samantha says she knows she is missing out on the high school experience, but she's looking at the big picture.
"I do realize I am missing out on a lot of things," said Sprole. "I think what I am doing now is more important for the long term."
Isabella Stanton is a 16-year-old senior at Mary Baldwin College and also a member of the P.E.G. program. She says the newcomers should expect to make mistakes, but they will grow from them.
"Over all I am please with it," said Stanton. "Of course there is certain aspects of it I wouldn't want to repeat, but over all I'm glad I came."
Officials say sometime students in the program do get home sick, but they try to build a family atmosphere for them.
"I'm sure for them it must be kind of frightening," said Judith Shuey director of P.E.G. "They are getting special support that traditional students are not getting, we give them a lot of attention, time and love."
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Word: Hotelterrasse
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tag:blogger.com,1999:blog-6277229251527832949.post5797119275006428949..comments2014-10-20T15:40:40.087-07:00Comments on Militant Medical Nurse: Shock Horror: Patient at Staffordshire Left without 0xygenNurse Annehttp://email@example.com:blogger.com,1999:blog-6277229251527832949.post-58379447731462070452012-03-06T15:08:31.220-08:002012-03-06T15:08:31.220-08:00This will not work as a matter of fact, that's...This will not work as a matter of fact, that's what I consider.
this siteemail@example.com:blogger.com,1999:blog-6277229251527832949.post-22287316189350648482010-12-10T08:09:36.924-08:002010-12-10T08:09:36.924-08:00This all sounds scarily familiar to me. I recently...This all sounds scarily familiar to me. I recently had the misfortune to end up in the A&E of a large central London hospital. For whatever reason I then became that 'breaching' patient and they all ran around like startled ants trying to decide who to blame if they couldn't shift me into the clinical decisions unit before the timer ran out.

A day later when they needed my CDU bed for the next breacher, I was pushed up to a top floor overflow ward which is basically a large room with no windows or phones and few equipment points on the walls, divided into bays by a few curtains. The porter then got cross with the ward nurse because they weren't ready for me and students were sent running to make up a bed.

A little while later all staff left, except one new nurse who seemed unfamiliar with her surroundings and didn't have a full grasp of the English language. She seemed a little overwhelmed to have been left alone in charge of 20-something patients for the night. I spent a scary night where I didn't receive my prescribed injections (although the vials sat in the cupboard by my bed), waited several hours for morphine and was kindly helped by the patient in the next bed (admitted for a Sickle Cell Crisis) who fetched me a bowl to vomit into when my call buzzer went (understandably) unanswered.

The next morning I told my doctor that I didn't feel safe spending another night there. My husband managed to arrange for us to take my treatment home and we managed to get me discharged before the following night.

Shortly before we left my husband had the misfortune of being the only non-patient in the room when a patient half a dozen beds away shouted out that the diabetic in the bed next to her had lost conciousness and begun fitting.

Patients are being mistreated because of financial cut backs causing a dangerous lack of staff and equipment and something must be done about this!A scared hospital firstname.lastname@example.com:blogger.com,1999:blog-6277229251527832949.post-67459301389612678392010-12-05T19:14:29.071-08:002010-12-05T19:14:29.071-08:00Hi there, Thanks for sharing this link - but unf...Hi there,

Thanks for sharing this link - but unfortunately it seems to be down? Does anybody here at militantmedicalnurse.blogspot.com have a mirror or another source?

Cheers,
email@example.com:blogger.com,1999:blog-6277229251527832949.post-53944320019605507972010-12-03T12:47:01.365-08:002010-12-03T12:47:01.365-08:00Oh god yes I did. I still cannot believe it.There...Oh god yes I did.

I still cannot believe it.There are people out there who believe that Nursing students don't work shifts on the ward anymore. Idiots.

I will stroke out if I read any more of those comments about Nurse training and the old days. People are so dumb.Nurse Annehttp://email@example.com:blogger.com,1999:blog-6277229251527832949.post-43645028442358746672010-12-02T21:14:26.095-08:002010-12-02T21:14:26.095-08:00Anne , have you seen the latest froth from the dai...Anne , have you seen the latest froth from the daily mail?:

http://www.dailymail.co.uk/news/article-1335211/Neglect-shames-Britain-campaign-touches-national-nerve-Mail-gives-50-000-patient-helpline-asks-readers-donate-can.html

Maybe they should campaign for better working conditions/more staff email@example.com:blogger.com,1999:blog-6277229251527832949.post-46940015574993764852010-11-29T05:09:08.870-08:002010-11-29T05:09:08.870-08:00I suggest wikileaks. Afterall, NHS IT is pretty su...I suggest wikileaks.
Afterall, NHS IT is pretty sucky and I doubt it would be difficult to break into.
I remember when the 4 hour targets first came in. The original idea was not a bad one- recognising that patients were spending too long lying on trolleys in A&E. However, it is a prime example of what happens when no clinical input was sought. Its 4 hours regardless of the problem. All of a sudden we realised that the REAL problem was the lack of beds to put patients into...so most A&Es ended with a small bedded area (used to be the drunk tank where I worked) that low and behold became the admissions unit. Job done! Unfortunately this didn't solve the bed crisis and so admissions units became the gargantuan monsters that we loathe today. Having that number of acutely ill people coraled together was suddenly starting to be expensive- hence the gradual whittling away of RNs and replacing them with a hoarde of support workers. Problem is, we know that they were a mistake but its one that can't be undone. Even if the targets were taken away, ED would still have to find beds for patients and the beds are just not there. I read with interest about a failing trust in the south of the UK that was been bought by a private company. This is the way we are heading. Acute care is expensive.Dino-nursehttp://firstname.lastname@example.com:blogger.com,1999:blog-6277229251527832949.post-63674668378994907392010-11-27T10:03:19.025-08:002010-11-27T10:03:19.025-08:00"Also, HCAs are allowed to start oxygen as lo..."Also, HCAs are allowed to start oxygen as long as it's prescribed. Is that even legal?"

unregistered staff can administer medication as long as the registered practitioner deems them competent. Have a look at the NMC standards for medication administration.

Anne, I know of wards where there are not enough flometers for all beds and they have big O2 cylinders to wheel up to patients who may reuire O2 in the situation like you have mentioned.

I've heard from other students when chatting that staffing is still poor at other trusts, another Stafford is inevitable. A close friend of mine ends up having to look after 27 acute medical patients with one other rn and 1 hca, the ther week she was on her own with 1 healthcare till midnight. I've sugested going to the press, but we all know what happens then. Margaret email@example.com:blogger.com,1999:blog-6277229251527832949.post-21953995279075452442010-11-27T07:17:16.782-08:002010-11-27T07:17:16.782-08:00Right on Sue! I remember when I was a student in ...Right on Sue!

I remember when I was a student in ED it was the ultimate sin for a patient to breach the 4 hour target.

Even if you were quiet in the morning and MAU were still swamped from the night before, the ED matron and bed manager were screaming at you to get the patient out!

What has the NHS come to when targets take priority over patient safety!

As for the O2 discussion, I was always reconnecting tubing if it disconnected or mask came off patients face when I was a HCA/student. God knows if I was violating trust firstname.lastname@example.com:blogger.com,1999:blog-6277229251527832949.post-74947865051998048162010-11-26T14:18:45.493-08:002010-11-26T14:18:45.493-08:00@Dino nurse; I work on an admissions unit as a H...@Dino nurse;

I work on an admissions unit as a HCA. The nurses call the ward to give handover. The porters, or us, then move the patient. The nurses only need to come if the patient is very unwell, on certain infusions, or a cardiac monitor.

Also, HCAs are allowed to start oxygen as long as it's prescribed. Is that even legal? The RN is responsible for checking the flow every 2 hours.

Admissions unit is a joke of nurisng care. I've even seen a patient being pushed to a ward in a bed with a tray of hot dinner on his lap, to "get that patient out before ED breeches". Disgusting. Oh, and the reason that things don't get done on those units? The bed manager sometimes takes the liberty of handing over to the ward (missing out half the stuff that is relevant) and then calling the porters, all without informing the RN's.

/rant email@example.com:blogger.com,1999:blog-6277229251527832949.post-2079164086656205062010-11-24T10:17:42.206-08:002010-11-24T10:17:42.206-08:00Ha i am not surprised that you guys are everyone&#...Ha i am not surprised that you guys are everyone's bitch. You are the only unit that even has RNs LOL.

The porters and an HCA or 17 year old cadet do the transfers. They literally dump and run.

We get a handover but they never tell you half of what you need to know.

The whole world revolves around AAU you know.

Once I was suctioning a patient (in the middle of meal time) and it was emergency. AAu called to give a handover. The hca told them that the nurse (me) could not take a handover now. A. because I was dealing with a patient who was unwell and B. because it was mealtime and 4 of us were trying to hand out meals and feed 20 people.

 They started screaming at her demanding to know excatly how many minutes it would be until I got to the phone to take the handover.

After I got off duty I walked down there and started laying into them. Felt good.

I got a NBM stroke patient with a low K up at midnight. The medical team had prescribed IV fluids around noon. Was not started until he arrived on the ward and I noted it.Nurse Annehttp://email@example.com:blogger.com,1999:blog-6277229251527832949.post-30455891229718391382010-11-24T07:58:03.942-08:002010-11-24T07:58:03.942-08:00This comment has been removed by the author.Dino-nursehttp://email@example.com:blogger.com,1999:blog-6277229251527832949.post-12486019769145484032010-11-24T07:57:56.157-08:002010-11-24T07:57:56.157-08:00This comment has been removed by the author.Dino-nursehttp://email@example.com:blogger.com,1999:blog-6277229251527832949.post-47607869371388462912010-11-24T07:57:48.949-08:002010-11-24T07:57:48.949-08:00The more things change, the more thay stay the sam...The more things change, the more thay stay the same. Unfortunately. I have friends who work in the community (mental health) who are currently being taken over by the private sector and it sounds dire.
I am shocked that any patient can be transferred to a ward from ED or MAU without a nurse escort. Do you get any sort of handover at all? Whoever is in charge of the shift (ED and MAU) needs reminding of their professional responsibilities as this has to be in breach of our code of conduct. In my own particular trust we have seen recent changes- porters would bring O2 if requested (ICU we always have loads anyway) and would usually attach the tubing for you and get you to check the settings before turning the canister on. As long as an RN had set the rate, if the tubing then came off, they could re-attach it. Attaching a piece of tubing is not rocket science afterall and they would not touch anything else. Plus the documentation for transfer indicates the rate so on arrival to, say xray, another RN had to tick that the rate was as stated. Now they are no longer allowed to attach the tubing (even if it pops off). HCAs are in the same boat- however in many cases it is HCAs and porters who transfer patients on general wards between departments (Xray etc)...so what are they supposed to do if O2 tubing pops off? I asked this at a senior staff meeting not so long ago and was told that wards would have to release RNs to transfer patients on O2 from now on. As far as I am aware, there have been no incidents concerning patient safety when HCAs and porters were allowed to reconnect tubing....the upshot is MAU now phoning ICU to see can they borrow an RN for a transfer. Ho hum. ICU seems to be everyones bitch at the moment.Dino-nursehttp://firstname.lastname@example.com:blogger.com,1999:blog-6277229251527832949.post-25010046707761231692010-11-23T10:47:54.867-08:002010-11-23T10:47:54.867-08:00I feel bad for you community matron. I know what ...I feel bad for you community matron. I know what kind of shit we are discharging into your care.

Patients are getting discharged way before they are ready.

They are closing down all the stepdown beds.

Community social services and district nurses cannot cope.

The wards are like bloody ITU.

The patients are unable to take care of themselves on discharge yet there are no services to help (that don't take 8 weeks to set up)

The hospital has no beds. We have to discharge people. Then they come right back in.

The families say"but you can't discharge gran because she cannot cope at home". Then they are yelling at us when we cannot get social services on board. WTF do they want me to do?

Sucks.Nurse Annehttp://firstname.lastname@example.com:blogger.com,1999:blog-6277229251527832949.post-25681171820652397912010-11-23T10:24:43.646-08:002010-11-23T10:24:43.646-08:00Come and work in the Community with us Nurse Ann, ...Come and work in the Community with us Nurse Ann, our "ward" has no boundaries and is not limited by bed spaces, we take everything that is thrown at us in increasing complexity and are expected to get on with it, when we can no longer cope with an individual because they are too sick to be cared for at home we admit them for them to be returned in a day or so worse than when we sent them in. Ontop of the invention of the forty hour day by our twat of a management team who like yours have largely forgotten what actually the job is about we have to attend a never ending and frequently growing amount of meaningless meetings to discuss more meetings and to make sure our service remains fit for the 16th century.... It's all great fun... The patients are great, the gps are great, the staff are great, but we can't carry on get g more and more complicated work with a decreasing and increasingly fragmented staff load.
As a Community Matron the future for Primary Care is terrifying!Community email@example.com:blogger.com,1999:blog-6277229251527832949.post-66001458929311040852010-11-23T09:56:53.692-08:002010-11-23T09:56:53.692-08:00I'd tell you to email me but I cannot get into...I'd tell you to email me but I cannot get into my gmail account.Nurse Annehttp://email@example.com:blogger.com,1999:blog-6277229251527832949.post-68659086228767876402010-11-23T09:56:35.066-08:002010-11-23T09:56:35.066-08:00Where FF where where?Where FF where where?Nurse Annehttp://firstname.lastname@example.com:blogger.com,1999:blog-6277229251527832949.post-84897460853217884882010-11-23T09:35:31.879-08:002010-11-23T09:35:31.879-08:00Aww Anne...that really really sucks! I'm lucky...Aww Anne...that really really sucks! I'm lucky my placement ward has plentiful O2 at every single bad and every nurse only has 6 patients to look after. They are recruiting here too, come work here!Frustrated Fairyhttp://firstname.lastname@example.com:blogger.com,1999:blog-6277229251527832949.post-82557727715013426192010-11-23T05:13:52.423-08:002010-11-23T05:13:52.423-08:00And guess what is even funnier than this. They us...And guess what is even funnier than this.

They used to keep high flow 02 masks (used in an emergency on the ward). But thanks to financial cutbacks they want to cut back on stock.

We were informed that these masks will not be distributed to every ward but rather they will be 2 floors up in the emergency supply cupboard for the entire hospital. It does not get restocked over the weekend.

You also need a code and to fight with the door to be able to get in and look for what you need. Not really something you want to be messing around in an emergency when you have abandoned your 19 patients to head two floors up to a supply cupboard.

Especially when you are getting stopped by elderly people who need directions to the car park every two seconds on your way to and from.

But the public will just blame the "cruel nurses" for "not wanting to be bothered putting granny on 02" when people get hurt. So really, what does management care?

Anyway I think we shot them down on the high flow masks in the cupboard 2 floors up thing. It shows you how they are thinking.Nurse Annehttp://firstname.lastname@example.com


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Ace x Impossible Project Starter Kit $150
If you aren't already familiar, THE IMPOSSIBLE PROJECT kept instant Polaroid film alive. When Polaroid decided to end their instant film program a few years ago and shut down their last factory in The Netherlands, Florian Kaps, a camera shop owner at the time, found a way to buy the factory and is now producing film that works with Polaroid cameras. Its still in its infancy, and not as user friendly as the original Polaroid film, but it has come a long way and we're stoked to support his analog efforts of keeping such an iconic photographic expression alive and more relevant today than ever. Learn more and submit a photo to our gallery here.
The Starter Kit has all the elements you need to begin the latest installment in your collection of instant photographs — a camera, a pack of film and a few extras for good measure, including our undying affection.
Instant film also sold separately.
Sorry, we have discontinued this product
Film Camera Polaroid Analog Impossible Project
Other Stuff Home Goods Archived


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Admittedly this column has nothing really to do with the Baltimore Orioles. However as a broadcasting major I was taught that radio guys were supposed to do the occasional Public Service Announcement (PSA). We hear them all the time; our favorite DJ's doing a commercial trying to get people to stop smoking, drinking, etc. So this is kind of in that direction. Today is election day in America, and as an American Government minor I feel that this is annually something to which we should pay attention.
Be you of the liberal or conservative ilk, your opinions matter. Obviously at this time last year we were at the end of a national election for the Presidency; while that's not something in play this year, numerous states are voting for governor, state delegate, senator, etc. I'm sure that various cities and towns have mayorships up for grabs also which in theory could be just as important if you believe the moniker that all politics is local. Plenty of juristictions also have numerous budget and bond issues on the ballot as well.
Voting on election day is more than just granting yourself the option of to complain for the next four years or whatever the case may be. Our government is for the people, thus the people should have a say in who runs it. So wherever you are and regardless of what you believe in, get out and vote today. It's a right guaranteed to you by the Constitution, and one that you should take seriously.
Tags: Baltimore Orioles


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Coakley strikes a defiant note as polls tip
A senior campaign adviser said the Globe poll that showed Baker as well ahead was an "outlier."
A senior campaign adviser said the Globe poll that showed Baker as well ahead was an "outlier."
Thomas Farragher
Like most of you, I was ready to vote against Question 2. Then came the deceit.
While some marketers seek harmless ways to make a quick buck, others deal in misinformation and profit off fear.
At Brigham and Women's Hospital, medical teams learned how to protect themselves from the virus.
Athletic programs emphasizing individual excellence come at the expense of the well-being of the nation's youth, some say.
Michael Moore had waited all day — really, all his life — for the whale to surface, the suffering giant that science had to save.
The Red Sox have a hole at third base, and the popular, switch-hitting Sandoval is a pending free agent.
Halloween attractions are pushing the boundaries, featuring scare tactics such as binding, gagging, and waterboarding.
Gary Gottlieb will leave the health care giant in 2015 to become the chief executive of Partners in Health.
editorial | endorsement
The Republican has more relevant professional expertise than incumbent Suzanne Bump, the editorial board writes.
Kansas City leads the series, two games to one, and can put the Giants away the next two nights.
Boston Mayor Martin Walsh vetoed a $20,000 raise for city councilors Friday, saying it needs "further independent analysis."
The shooting at Marysville-Pilchuck High School forced hundreds of students to hide in classrooms and then be evacuated to a nearby church.
The five candidates aired their differences during a forum on Latino issues at Northeastern University.
After an embattled summer, the grocery chain will add more than 1,000 new jobs in a five-store expansion.
You know this isn't your grandmother's opera when conductor Mandisi Dyantyis takes the stage in a white T-shirt and camouflage cargo pants.
There may be a time and place for bad beer, but there's no arguing that it's better.
Take a look at a selection of the entries that will be judged in three categories: people, places and nature.
Oct. 31
Ever wonder what it takes to produce the Boston Globe every day? Here's your chance to find out.
As climate change jeopardizes the huge ocean claims of tiny nations, experts propose some bold legal solutions.
Continue reading by subscribing to BostonGlobe.com for just 99¢.
Continue reading by subscribing to BostonGlobe.com for just 99¢.


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From Wikipedia, the free encyclopedia - View original article
William Apess (1798–1839), also known as William Apes before 1836-1837, was an ordained Methodist minister, writer, and activist of mixedblood Pequot descent who was a leader in Massachusetts. After becoming ordained as a Methodist minister in 1829, he published his autobiography the same year. It is among the first autobiographies by a Native American writer.
The scholar Patricia Bizzell described him as "perhaps the most successful activist on behalf of Native American rights in the antebellum United States."[1]
An itinerant preacher in New England, Apess visited the Mashpee on Cape Cod in 1833. Hearing their grievances, he helped organize what was called the Mashpee Revolt of 1833-34. Their attempt to regain civil rights was covered sympathetically by the Boston Advocate. Apess published a book about the experience in 1835, which he summarized as "Indian Nullification". Apess alienated many of his supporters before dying in New York City, New York at age 41.
William Apess was born in 1798 in Colrain in northwestern Massachusetts to William and Candace Apess of the Pequot tribe.
According to his autobiography, Apess' paternal grandfather was white and married a Pequot woman.[2][3] He claimed descent from King Philip through his mother, who was also of European-American and African ancestry.[4] Until the age of five, Apess lived with his family, including two brothers and two sisters, near Colrain.[5]
After his parents separated, the children were cared for by their maternal grandparents, who were abusive and suffered from alcoholism. After continued abuse, a neighbor intervened with the town selectmen on behalf of the children. They were taken away for their own safety and indentured to European-American families. The then five-year-old Apess was cared for by his neighbor, Mr. Furman, for a year until he had recovered from injuries sustained while living with his grandparents. Apess was sent to school during the winter for six years to gain an education, while also assisting Furman at work.[5][6] As a child he was taken to Methodist gatherings and became faithful to the religion.
Apess ran away at the age of fifteen and joined a militia in New York, fighting in the War of 1812. By the age of 16, he became an alcoholic and struggled with alcoholism for the rest of his life. From the years 1816 to 1818, he worked at various jobs in Canada.
Troubled by his alcoholism, Apess decided to return home to the Pequot and his family. Within a short period of time, he reclaimed his Pequot identity. He attended meetings of local Methodist groups and was baptized in December 1818.
In 1821, Apess married Mary Wood, also of mixed ancestry, and the couple had one son and three daughters together.[5] After Mary died, Apess later remarried. He and his second wife settled in New York City in the late 1830s.
After his marriage to Mary, Apess felt his vocation was to preach. In 1829 he was ordained as a Protestant Methodist minister.[7] In the same year he published his autobiography, A Son of the Forest: The Experience of William Apess, A Native of the Forest, Comprising a Notice of the Pequot Tribe of Indians, Written by Himself. Apess' work was one of the first autobiographies published by a Native American and was published partly in reaction to advocates of Indian Removal, including Andrew Jackson. He used the common format of the time of the spiritual conversion to comment also on European-American prejudices against Native Americans.[8]
As was the Methodist practice of the day, Apess became an itinerant preacher; he preached in meetings throughout New England to mixed congregations including Native American, European-American, and African-American audiences. While preaching in the Wampanoag dialect of the Algonquian language family, he used English language and cultural precepts to raise issues of Indian rights to European-American audiences and "to serve Indian political ends."[1] In 1833, following a visit to the town of Mashpee, the largest Native American town in Massachusetts, Apess became convinced the State was acting illegally in denying self-government to the Mashpee Wampanoag.
He participated in the so-called Mashpee Revolt of 1833-34, in which the Mashpee took action to restore their self-government: they wrote to the state government announcing their intention to rule themselves, according to their constitutional rights, and to prevent whites from taking away their wood (a recurring problem). In May 1833 the Mashpee tribe wrote to Harvard College, which administered the Williams Fund: this paid for a minister to them, although they had never been consulted in his appointment. They objected to Rev. Mr. Fish, who had long been appointed to them, they did not like his preaching, and said that he had enriched himself by appropriating hundreds of acres of woodland at the tribe's expense.[9] Lastly, they prevented a settler, William Sampson, from taking wood away from their property and unloaded his wagon. Three Indians were indicted for riot and Apess was jailed for a month as a result.[10] An attorney assisted them in successfully appealing to the legislature, but initially their actions were responded to by Governor Levi Lincoln, Jr., threatened the group of military force.
The issues were reported sympathetically by the Boston Advocate through June and July.[11] The Mashpee protest followed the Nullification Crisis of 1832 on the national level, and the historian Barry O'Connell suggests that Apess intended to highlight the Mashpee attempt to nullify Massachusetts laws discriminating against Native peoples.[12]
During the period 1831-1836, Apess published several of his sermons and public lectures, and became known as a powerful speaker. But, struggling with alcoholism and increasing resentment of white treatment of Natives, he gradually lost the respect in which he had been held; both white and Mashpee groups distanced themselves from him. In 1836, he gave a public lecture in the form of a memorial eulogy for King Philip, a seventeenth century Indian leader who was unjustly assassinated by the Plymouth colonists after the colonists had poisoned his brother and violated several treaties. Philip's head was then stuck on a stake and his hands cut off, given as presents to the spies that betrayed him. After publishing his lecture, Apess disappeared from New England public life. He moved to New York City with his wife and children, trying to find work.
At the age of 41, William Apess died of a cerebral hemorrhage (stroke) on April 10, 1839 at 31 Washington Street in New York City.[13] He lived there with his second wife.


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GCC provides an exploratory look at Oregon's well-known Columbia Gorge with depth and detail rarely found in any adventure guide. The very heart of this book offers informative route beta, detailed ink topos and photographic maps designed to orient you to your next off-trail Gorge climbing adventure.
Within this 74-page booklet you will find a unique selection of classic and historical adventures such as:
- Rooster Rock & West Chimney on Crown Point
- Chimney Rocks southeast of Silver Star Mtn.
- St. Peters Dome & Katanai Rock
- Wind Mtn & Windy Slab
- Apocalypse Needles such as Apollo Column & Fire Spire
- Cigar Rock on Cape Horn
- ROA Point, NE Buttress of Yeon, and the Island below Nesmith Pt.
Interesting off-trail adventures exploring various Gorge creek systems or ridge lines often following deer and bear trails or traversing along other lesser traveled paths.
Much of the flavor of this guide is devoted to those who relish the off-trail climbs and adventures of the Gorge. It is NOT a sport climbers guide, NOR a general hikers guide. Most of the adventures and climbs require sufficient experience in a rock climbing/technical sense using skill, insight, terrain navigation knowledge, use of climbing gear, ascending exposed steep cliffs, and traversing along slippery waterways. Gorge climbing and adventuring is in a league of its own, and is every bit as challenging as when turn-of-the-century explorers tread upon this wild place. Due to the nature of the forested terrain and steep layered tiers of basalt cliffs those who choose to pursue any destination in GCC should use every precaution necessary to adequately assure a safe return. Though there are technical ratings listed in GCC, in reality most of the climbs listed are either PG, R, or X.
The goal of this booklet is to provide comprehensive Gorge climbing information that has not been available in a guide since the Neuberger guide in the late 1950s and the Dodge analysis in the late 1960s.


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These high-impact, molded shoulder pads protect against harsh checks from your opponents. They feature a super-soft liner that will provide you with comfort and keep you dry all game long. You can adjust or remove the biceps pads, enabling you to customize your pads to your liking for ultimate performance on the field.
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July 2009: Volume 35, Number 7
Vitamin D Testing—What's the Right Answer?Labs Grapple with Confusing Analytics, EvidenceBy Genna Rollins
A decade ago, the main reason physicians ordered a vitamin D test was if there was a concern about the patient's bone density. However, a flurry of research now has implicated the prohormone in a host of conditions, including among others, certain cancers, type 1 diabetes, multiple sclerosis, tuberculosis, Alzheimer's disease, psoriasis, and all-cause mortality, while also indicating that vitamin D insufficiency is prevalent. Even though vitamin D's mechanism of action in the prevention or progression of various diseases has not been established definitively, these studies have been picked up by the popular press, causing demand for vitamin D testing to skyrocket. At the same time, there have been notable technological advancements in vitamin D testing, controversies surrounding certain tests, and considerable confusion about both analytical considerations and clinical interpretation of vitamin D results, leaving laboratorians and clinicians unsure about how to implement or interpret the test properly.
"We are ahead of the evidence. The good reasons and good justification was not there to do so many tests as we are doing now," contended Ravinder Singh, PhD, DABCC, co-director of the endocrine lab at the Mayo Clinic. "Every year millions of tests are being ordered and now we are running into a situation where doctors are confused, labs are confused, and the only reason we're confused is because we're not ordering this test on the right patient population." Volume at the Mayo Clinic, which uses a liquid chromatography tandem mass spectrometry (LCMS) method, has increased to > 61,000 tests per month in December 2008, up from >19,000 per month in July 2006.
Surge Evident in Utilization Survey
CLN's recent email survey bears out the increased volume of testing, as well as ambiguities surrounding use of the vitamin D test (see Box, below). More than 50% of respondents indicated that the volume of 25-hydroxyvitamin D (25-OH-D) testing in their labs had increased by at least 50% in the past year, with 27% indicating that volume had gone up by more than 100%. While much more modest, increased volumes also were reported for fractionated 25-OH-D testing and 1,25-dihydroxyvitamin D (1,25 (OH)2 D) testing. In the case of the relatively new fractionated 25-OH-D test, which breaks out total 25-OH-D and individual levels of 25-hydroxyvitamin D2 and 25-hydroxyvitamin D3, 32% of participants who said their labs perform the test indicated that the volume has increased by at least 50% in the last 12 months. At the same time, while 40% of participants who said they perform the 1,25 (OH)2 D test assay indicated that there had been no change in volume during the past year, nearly one-quarter reported an increase of up to 25%, and 13% reported a 50% or higher increase in volume, which appears to be out of sync with the test's limited diagnostic indications for assessing parathyroid disease and calcium metabolism disorders.
The out-of-kilter 1,25 (OH)2 D volume is no surprise to lab directors who are finding that not all physicians know which test —25-OH-D or 1,25 (OH)2 D—is correct for determining overall vitamin D status. "Fifty percent of physicians are still confused about what is the appropriate test. Some clients order both and one comes back normal and the other's not. Then they call me and ask, 'what should I believe?' and I have to explain the difference," observed L.V. Rao, PhD, director of core laboratories and associate professor of pathology at
UMass Memorial Medical Center in Worcester. The UMass lab, which is a referral lab for Massachusetts and surrounding states, performed 400 to 500 vitamin D tests per month 3 to 4 years ago, but now is running between 12,000 and 13,000 per month, according to Rao.
"There's significant confusion out there," agreed Hershel Raff, PhD, director of the endocrinology research laboratory for ACL Laboratories and professor of medicine at the Medical College of Wisconsin in Milwaukee. "Vitamin D testing's becoming part of the routine physical in Wisconsin, but some doctors don't really understand what they're ordering, so they check off anything that looks close." Raff believes the vitamin D naming conventions only muddy the waters: 25-hydroxyvitamin D2 also is known as ergocalciferol, 25-hydroxyvitamin D3, as cholecalciferol, and 1,25 (OH)2 D, as calcitriol. Some doctors mistakenly think 25-hydroxyvitamin D2 or 25-hydroxyvitamin D3 is the same as 25-OH-D or 1,25 (OH)2 D. Testing volume for 25-OH-D at ACL Laboratories has increased more than 50% in the past year. The spike over the last several years was so significant that Raff retired a manual radioimmunoassay (RIA) and brought in two automated immunoassays. "When we started we were only doing about 90 tests a week, then it got to where I would have had to hire five people to keep doing it manually," he explained.
Overview of Vitamin D TestingCLN Survey Reflects Volume Increases, Analytical Challenges
CLN recently conducted an e-mail survey of readers to learn about their experiences with vitamin D testing. Respondents came from a variety of settings: 37% reference labs; 21.8% academic medical centers; 20.9% private hospitals; 15.6% state/county/local hospitals; 4.7% veterans/military hospitals (n=212).
What vitamin D test does your lab perform?
How has the volume of vitamin D testing at your lab changed over the past 12 months?
Selected Comments from Survey Respondents
Survey respondents had a lot to say about vitamin D testing.
"These analytes need standardization and a consensus on appropriate reference ranges. I question the utility of most of these measurements in patient management."
"We think we have it right at this time. Waiting to see if further research might change the sufficiency cutoff to a higher number."
"Providers in my institution order vitamin D levels on EVERYONE due to the trendy nature of the test, in my opinion. Also, after clinical interventions are made/adjusted, our providers are rechecking Vitamin D levels monthly, and that is both clinically insignificant and really hampering our ability to ensure good turnaround time."
"There is so much misinformation on vitamin D testing."
"Our vitamin D volumes have skyrocketed in the past 2 years from 1-2 /month to our current volume of >200/month. We are watching the market closely for a method or methodology that will fit our lab. Space, cost per reportable, and staffing are issues we must consider to bring a new procedure in-house."
What's the Right Reference Range?
In concert with the confusion about which vitamin D test to order, there is no consensus about the appropriate reference range and cut-offs for deficiency or insufficiency, as well as optimal and possible toxicity status. Studies have identified various ranges for disease risk reduction, and labs use a variety of ranges, which was reflected in CLN's survey. Reported deficiency levels for 25-OH-D started at ≤8 ng/mL and went all the way up to ≤30 ng/mL. The same discordance was reflected in reported insufficiency ranges, which varied from 8 to 20 ng/mL to <32 ng/mL. Sufficiency and/or optimal ranges also had quite a number of reported cutpoints, from 25 to 80 ng/mL and 31 to 150 ng/mL to 32 to 100 ng/mL and 50 to 80 ng/mL. Likewise, reported possible toxicity levels included >80 ng/mL, >100 ng/mL, >150 ng/mL, and >200 ng/mL. Although a consensus among vitamin D researchers is coalescing around <10 ng/mL as an indication of deficiency, 10 to 30 ng/mL for insufficiency, 30 to 100 ng/mL for sufficiency, and >100 ng/mL for possible toxicity, clearly there is room for further evidence and agreement.
This variation is due in large part to the reference ranges being based on recommended levels from studies rather than actual analysis of serum. "If you take the classic approach of determining the normal level of calcium in the blood, for example, you'd get 100 samples from your reference population and measure calcium and define the reference range as plus or minus two standard deviations," explained Reinhold Vieth, PhD, FCACB, clinical chemist and director of the Bone and Mineral Lab at Mt. Sinai Hospital in Toronto. "The problem with vitamin D is that the reference sample will be different depending on what city you're in, what your subject profile is, and whether it's winter or summer. Vitamin D is somewhat like cholesterol levels, in that you're not looking at what is 'normal'; you're looking at what is optimal or desirable. It's a literature range, not a population range."
Perhaps because of the rising volume and lack of consistent uses for vitamin D testing, National Government Services (NGS), a major Medicare contractor with claims processing in at least 16 states, proposed a new vitamin D payment policy in February. NGS planned to end payment to labs and physicians for routine testing for vitamin D deficiency, except for patients with chronic kidney disease, osteomalacia, hypercalcemia, and rickets. Following comments from professional organizations such as The Endocrine Society, NGS modified the policy to include osteoporosis, hypocalcemia and vitamin D therapy follow-up as indications for testing. The new policy was to become effective July 1, 2009 but reportedly has been extended to September 1 to allow for further review.
AACC to Hold Audioconference on Vitamin D Testing
This fall, AACC will host a 90-minute audioconference that examines the analytical challenges and clinical implications of testing patients' vitamin D status. Moderated by André Valcour, PhD, of LabCorp, the program will address the various types of technologies used to perform vitamin D testing today, as well as examine issues such as standardization and reference ranges. For more information, visit the AACC website and look for the program under "Upcoming Events." Supported in part by an education grant from DiaSorin.
Analytical Challenges
Yet another level of confusion exists as a result of several lingering analytical issues with the various assays. The RIA manufactured by Diasorin is the predicate FDA device and the one used on most studies to establish vitamin D reference ranges. Since the RIA's introduction in the early 1990s, newer generation versions of the assay have been released, and more recently new vitamin D testing methods have emerged, including high performance liquid chromatography (HPLC) and LCMS, which are laboratory-developed tests.
According to Rao, it is not uncommon for physicians to receive vitamin D test results for the same patient but from different labs that have used different assays and produced different results, putting laboratorians in a spot to explain the discrepancies. For instance, UMass Memorial Medical Center uses both an immunoassay and LCMS to measure 25-OH-D. Rao analyzed results from the two methods and found that with both using a cut-off of <30 ng/mL for insufficiency, 68% of results from the immunoassay indicated insufficiency, whereas only 30% of LCMS results were below that level. Based upon that analysis, Rao conducted a separate study using both methods on samples from 600 patients. He found there was up to 40% positive bias towards LCMS.
Rao's experience is not isolated. Richard Garcia-Kennedy, MD, laboratory medical director at California Pacific Medical Center (CPMC) in San Francisco conducted a similar analysis. CPMC does not perform 25-OH-D testing, and uses two different reference labs, one that operates an immunoassay method and one that runs LCMS. In the same 1-month period, results from the lab that employs the immunoassay indicated that 79.8% of patients had vitamin D levels <32 ng/mL, which was the stated lower range of normal, while the other lab reported that 46% of patients had vitamin D levels <32 ng/mL. "The forty six percent below 32 ng/ml is believable because our population is dark-skinned, we have foggy summers, and a large Asian population which is very lactose intolerant. But the eighty percent makes no sense," said Garcia-Kennedy. Busy primary care physicians were even more befuddled by the results because the lab that uses LCMS reported <20ng/mL as the deficient or abnormal level, with additional verbiage on test reports indicating that >32ng/mL is an optimal level. "Remember, the primary physician or his or her assistant in the trenches is scanning reports for abnormal flags and will not necessarily be conversant with the issues of 20 versus 32 ng/mL for normal," explained Garcia-Kennedy. Using the <20ng/mL metric, the LCMS-immunoassay differences were even more pronounced, and a source of vexation for the affected practices.
After reviewing the discrepancies with CPMC's endocrinology department, Garcia-Kennedy has essentially thrown in the towel vis-à-vis vitamin D testing. "When people ask me about vitamin D, I say 'don't even bother measuring it. Just take 500 IU of vitamin D daily, because it makes absolutely no sense from the practitioner's perspective.' There's a lack of foundation here still, that makes these numbers not useful," he contended.
The U.K.-based Vitamin D External Quality Assessment Scheme (DEQAS), the largest vitamin D proficiency testing program with more than 600 registered participants, including 225 labs from the U.S., likewise has observed extensive interlaboratory variation. A 2008 review found that the annual mean interlaboratory imperfection has generally declined from near or about 30% in the mid 1990s to just under 20% in 2007, with sporadic increases as new methods were introduced and problems with certain assays were identified. Significantly, the DEQAS analysis revealed that between April 2007 and January 2008, the LCMS method produced a mean positive bias >10% from the all-laboratory trimmed mean (ALTM). "The LCMS method was a huge advance with vitamin D, but it's giving higher values for reasons we don't understand," noted DEQAS organizer Graham Carter, MSc. CAP also performs vitamin D proficiency testing.
The Gold Standard?
While LCMS is becoming the preferred analytical method of many reference labs and has been called the gold standard for measuring vitamin D, not all lab directors see it that way. "Mass spec is the gold standard to give you an idea of the molecular weight of a compound passing through the machine, but not the amount of that compound," said Vieth. Detractors of using LCMS for vitamin D testing also point out that results are subject to each lab's individual reference procedures and calibrations, which adds to the imprecision.
"It's a wild west show. There are no standardized procedures, no FDA oversight, and both HPLC and LCMS are very user dependent and user interpretative," argued Bruce Hollis, PhD, professor of pediatric biochemistry and molecular biology and director of pediatric nutrition services at the Medical University of South Carolina in Charleston. Hollis was instrumental in developing the predicate RIA and is a paid consultant to Diasorin, a leading manufacturer of vitamin D immunoassays. Singh countered that the Mayo Clinic's LCMS method has proven to be analytically stable with no biases or trends observed in a 2 ½ year observation period. Performance data from the lab's calibrators indicated a CV of <3%.
Hollis has argued that the LCMS methods should be calibrated to the RIA, but Carter thinks that would be a mistake. "Intuitively you'd expect LCMS to be more specific and that it will be more likely to give 'the right answer' than an immunoassay, which is subject to all kinds of interferences, matrix effects, and the like," he explained. "So the idea of calibrating a mass spec method to an immunoassay, however good the immunoassay, is simply a bad idea."
To sort out the problems observed with the proficiency testing surveys, DEQAS has commissioned the development of a new gas chromatography-mass spectrometry (GCMS) method for measuring vitamin D and expects to use the method to check the validity of the ALTM and provide values for 25-OH-D3 and 25-OH-D2 on at least some samples, according to Carter. The GCMS method might also help further establish LCMS as the gold standard by providing a method to check it against, he added.
Meanwhile, the vitamin D immunoassays have had their own share of challenges. Diasorin recalibrated its RIA with new antibodies in the late 1990s and recently modified its automated immunoassay. IDS also recalibrated its immunoassay in 2006. These changes have caused a methodological drift, with variable results from the immunoassays over time. For instance, in 2004 the Centers for Disease Control and Prevention reanalyzed a subset of 150 banked serum samples using the updated Diasorin RIA kit which originally had been included in NHANES III (1988–1994) and had been tested with an earlier version of the Diasorin RIA kit. The results indicated that data obtained using the new RIA were on average 11.7% lower than data obtained from the old RIA.
Adding to the controversy about testing methodology, Quest Diagnostics and its subsidiary Nichols Institute Diagnostics experienced well-publicized problems with Nichol's immunoassay for parathyroid hormone testing, and in April 2009, Quest and Nichols made a $302 million settlement with the U.S. Department of Justice to resolve civil and criminal claims concerning that test and a 25-OH-D assay, among others. Separately, Quest acknowledged in 2008 that for a period of about 18 months from early 2007 to mid 2008, the company's new LCMS method for vitamin D testing possibly was reporting erroneous results. Quest offered free retesting for affected samples, said to be <10% of the company's total vitamin D testing volume. In a New York Times article, the problems were attributed to some faulty materials being used to calibrate test results and not all Quest labs consistently following proper procedures.
Hope on the Horizon?
Even as there has been a trail of confusion in vitamin D analytics, there is, in the eyes of many, hope on the horizon. NIST has been developing serum and solvent-based standard reference materials for 25-OH-D (SRM 972 and SRM 2972, respectively). As CLN went to press, SRM 972 was about to be released, while SRM 2972 was expected to be available by the end of July 2009, according to Karen Phinney, PhD, research chemist at NIST. In theory, the SRMs will provide both immunoassay users (in the case of SRM 972) and LCMS users (in the case of SRM 2972) a means to calibrate their assays, reducing the interlaboratory CVs for each method. One study found that harmonization to a common calibrator reduced average between laboratory variation to 9% from 30% (DOI:10.1373/clinchem.2008.107847). Mayo's Singh has argued that the industry should aim for a CV <1% (DOI:10.1373/clinchem.2007.096156).
However welcome the SRMs may be, not all researchers see them as a panacea. For instance, Hollis believes SRM 972, which includes four serum pools, "will cause more confusion than it will solve." The first pool, which represents 'normal' serum, will work across the board with the various assays, according to Hollis. But he expressed concerns about the second and third pools. In those cases, he contends that the standard will work well for methods that physically destroy the proteins, but in the case of newer tests that rely on displacement of analyte from the binding protein without destroying the protein, then those standards will not work as well. He attributed this to artifacts emanating from the standards themselves, for example, equine serum used in the second pool and exogenous 25-hydroxyvitamin D2 spiked to the third pool.
NIST's Phinney, however, defends the SRMs. "SRM 972 was developed in consultation with a panel of experts in the vitamin D field," she explained. "Each of the four levels of SRM 972 is intended to pose a different measurement challenge, and individual users will need to assess which levels best suit their particular needs."
NIST also has been developing a reference measurement procedure (RMP) for vitamin D testing, as defined by the Joint Committee for Traceability in Laboratory Medicine (JCTLM). According to Phinney, NIST expects to publish the method within the next few months and subsequently submit it as a candidate RMP to the JCTLM.
As labs await release of the reference materials and methods and aim to improve vitamin D analytics, some, like Rao, have proposed using a conversion factor to adjust LCMS results downwards in order to use the reference ranges derived from RIA-based testing. Carter has suggested that this would be "akin to 'cooking the books' (albeit with the best of intentions)" (DOI:10.1373/clinchem.2009.125906). Rao found that the conversion factor only confused physicians more, as they were uncertain about which level to consider in clinical decision-making. For now many labs, UMass Memorial Medical Center among them, are reporting RIA reference ranges with LCMS results. However, laboratorians doing so may share Rao's misgivings. "I'm uncomfortable using the same reference ranges for LCMS and our immunoassay because I know we have a difference," he said.
Gritting our Teeth
As the vitamin D field continues to evolve, there are steps laboratorians can take to improve vitamin D testing proficiency and inform the medical community about the test's appropriate use. Raff spends a good bit of time educating physicians one-on-one, in group presentations, and in writing, including in an internal newsletter that detailed the biochemistry of vitamin D and the differences between 25-OH-D and 1,25 (OH)2 D testing and their respective indications.
In organizations with computerized physician order entry (CPOE) systems, pop-ups that steer the physician to the correct vitamin D test can be helpful, according to Greg Sephel, PhD, FACB, clinical laboratory director for the VA Tennessee Valley Healthcare System and associate professor of pathology at Vanderbilt University in Nashville. "In teaching institutions with high provider turnover the key to communication is realtime information, and the best way to accomplish that is by setting up the computer to help with ordering patterns and interpretations," he said. When CPOE is not available, Raff recommends removing 1,25 (OH)2 D from check-off lab requisition lists so that physicians will have to write in the test to order it.
The upswing in vitamin D testing volume is attractive for labs that want to increase their billable tests, but labs currently not performing the test should think carefully before bringing it in house, according to Sephel. "It's not simply a make-or-buy cost decision. If you're bringing in a new machine, you have to consider whether it's completely, semi, or unautomated and how much labor and training it will entail, and you have to account for running controls, maintenance, proficiency testing, calibrations and quality of the test," he explains. Those factors, along with staff shortages due to retirements and lack of space due to renovations, lead Sephel to decide for now that vitamin D testing will continue to be a send-out from his lab.
Sephel urged all laboratorians to stay on top of vitamin D testing, even if their labs do not perform the test. "For many labs this remains a send-out test, and there is a tendency not to have as much knowledge about methods and interpretations of those types of tests, but I think it's important that we're involved. We need to do what we can to make sure the test is being ordered and interpreted properly," he said.
While the industry awaits analytical improvements and further clinical evidence about vitamin D, laboratorians will be challenged to maintain high-quality testing and keep physicians well-informed about testing indications. As Carter put it, "We'll just have to grit our teeth."
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First Cub
Big Bend Series #2
Black Bear
Bears disappeared from the Big Bend country early in the 20th century. Their recent reappearance in the National Park has created much excitement. Black bears have migrated in from the mountains of northern Mexico and established a resident population again in the park, many being spotted on New Year's Day – what a welcome to 2010! These animals are monitored, where possible, to preserve a healthy bear population and prevent dangerous visitor/bear encounters.
"First Cub" by Bob Coffee
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Our next Warehouse Market is this coming weekend, May 30th & 31st. The Bliss Lounge will be inside the warehouse and opened up for you to check out. Paris Montana won't be with us this time, she is off on an adventure in Montana! Go figure. :)
I've got lots of new finds, new jewelry, and new vintage trailer t shirts!
I've got a couple of these super cool vintage looking flag scarves available too. They are perfect for the upcoming 4th of July holiday and decorating.
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I'll post some more peeks this week, but also Follow me on Instagram @vintageblissaz
and Facebook Here. More to come! Stay tuned.
Blissfully Yours, Tricia


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Study abroad!
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"I think the regime in Damascus is approaching collapse," he told reporters after a meeting with the Dutch prime minister at NATO headquarters. "I think now it is only a question of time."
While NATO member states have made similar predictions before, the assertion by Mr. Rasmussen, the leader of the Western military alliance, reinforced a growing consensus that Mr. Assad's options for remaining in power had been all but exhausted — a view now apparently shared by Russia.
Top Russian Envoy for Syria and NATO Leader Say Assad Losing Control – NYTimes.com
Tagged with: NATO • Nato Headquarters • NATO Leader Say Assad Losing Control • Top Russian Envoy
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My face once I finally meet my family in Paris
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29 Nov 13
Jarvis Landry Ripped The Ball Away From Florida Defensive Back
SEC strength and coordination.
28 Sep 13
2014 NFL Draft Prospects to Watch This Weekend in College Football
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07 Sep 13
Jarvis Landry Made the Catch of the Season for a LSU Touchdown
Full extension.


text: lokks like we will be there also Malfretha plus 3 bringing... hmmm.... marshmallow popcornballs and some other goodies On Fri, 27 Oct 2000 09:37:46 EDT LdyCalais at aol.com writes: > Greetings, > You guys are WONDERFUL!!!! I would like a head count if > possible > though. If your children are participating or if you will have > children with > you please add their name(s) to the list. Also if you know of > anyone not > connected to the net, please let me know or contact them to let me > know. We > sure don't want any disappointed kiddies! You know they ARE our > future. LOL! > Under the children(s) names please add your name and what you are > bringing. > Sorry for the time consumption but.... > In Service, > Lady > Elisabeth de > Calais > 1. Olivia de Calais > Elisabeth de Calais-Rice crispy treats > 2. Anthony of Northkeep ________________________________________________________________ YOU'RE PAYING TOO MUCH FOR THE INTERNET! Juno now offers FREE Internet Access! Try it today - there's no risk! For your FREE software, visit: http://dl.www.juno.com/get/tagj.


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How will my boxy tip nose look like after surgery?
- Hardy12345
- 2 years ago
Comments (1)
Hi there and welcome to RealSelf! Sadly, no surgeon is going to be able to tell you exactly how your nose will turn out, especially a surgeon who's not operating on you. If you don't trust your surgeon, I strongly urge you to find a board certified facial plastic surgeon who you do trust. You really don't want to have to get a revision, cuz they're a really difficult surgery and very expensive. Make sure you communicate extensively with whatever surgeon you choose so they know exactly what you do and don't want. Good luck!


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Entries with no category
I'm back? What?
Yeah. Kinda sorta. eue
I start high school today. ;u;
So I won't be on much... sorry guys! If you desperately need to find me I'm PimaBean on DeviantArt. c:
I'm back!
run for your lives
I'm gonna be gone for today and tomorrow, possibly the next day too. c: I'll try and reply to RPs when I'm back, sorry for the abrupt leave! <;
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this could be a draft, but I felt like making some trolls angryface c:
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mods please don't kill me
I have cameras so you'll never be able to hide my body
o = not done
- = half done
x = done
Start The Gladiator Pits -
Fear Itself Chapter One


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September 16, 2013 at 9:13 AM
Smart Monday/Positioning
By James Glover
Once a Day Marketing
James Glover, That Branding Guy, provides the inspiration and ideas for you to build more mindshare and capture marketshare with your customers in his Once a Day Marketing blog. Tune in often to his short, entertaining and practical marketing and branding tips and watch your organization become more successful and profitable.
Once a Day Marketing™ featured video blog: Branding in Non-Mature and Mature Markets
Hello, I'm Jim Glover, That Branding Guy for Once a Day Marketing™. Today is Smart Monday and we're going to take a quick look at branding in a mature market.
A mature market is defined by the fact that the product or service category has several brand leaders. For example, if I asked you to name a top cola you'd probably mention Coke and Pepsi. These are category brand leaders in the mature soda market.
In a mature market it's more challenging to create top of mind with potential customers, especially if you are trying to compete head to head with the category leaders. The best strategy is to differentiate your offering by focusing on a unique attribute that competitors aren't offering.
Let's take a look at an example. In Santa Fe there is a restaurant called Maria's. It doesn't boast that it's the best restaurant in New Mexico or even the best New Mexican restaurant in Santa Fe. It does promote having the largest selection of margaritas anywhere. Whenever you ask a local in Santa Fe where is the best place to find a margarita, Maria's is always top of mind. By creating this unique positioning in the restaurant category, Maria has captured substantial market share as well.
If your brand is situated in a mature market capture more market share by promoting your unique positioning.
Once a Day Marketing™ positions brands to become #1 in the minds of target customers. Visit our website at www.onceadaymarketing.com. Contact James Glover at (505) 501-1330 or email firstname.lastname@example.com. Listen to Ask Those Branding Guys™ every Monday at noon (MDT) streaming live on SantaFe.com KVSF 101.5 FM.
© 2013 Once a Day Marketing™. All rights reserved.


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