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Module 2 – Blood Transfusion
Introduction You will need to be competent in all areas of blood transfusion prior to becoming a PRHO; This module will direct your learning but it is up to you to put the knowledge and skills into practice. The skills should be attempted in a skills centre before being practiced in the clinical setting.
Aims and Objectives This module is designed to direct your learning around the knowledge and skills associated with blood transfusion By the end of this module students should be Aware of the 'when, where, why and who' of blood transfusion Aware of the steps necessary to order a blood transfusion and the common reasons why this process fails Able to write up a blood transfusion Able to set up a blood transfusion Aware of the common complications of blood transfusion and their treatments Calculate the required drip rate for a unit of blood
Challenging Knowledge - I For each of the following patients list:- (a) If you would transfuse them and (b) How many units you would give them, if any. (c) What other investigations would you order; What further management would you think about (1)23 yo asymptomatic, healthy woman with menorrhagia - Hb 8.9 g/dl, MCV 73fl (2)86 yo asymptomatic man with occasional angina – Hb 9.6 g/dl, MCV 104fl (3)61 yo man with severe gram negative sepsis – Hb 7.0 g/dl, MCV 81fl (4)54 yo woman post hemicolectomy Hb 8.3g/dl, MCV 84fl (5)73 yo man presenting with acute upper GI bleed; BP 80/60, Pulse 120 thready – Hb 8.0 g/dl, MCV 101fl
PatientHb (g/dl) MCV (fl) TransfusionOther Treatment 23yo female Menorrhagia leading to iron deficiency anemia 8.973No transfusionFeSO 4 Investigate if severe 86yo male Macrocytic anaemia No transfusionInvestigate for macrocytosis Drugs, Alcohol, Hypothyroidism, Haemolysis 61yo male Severe G negative sepsis leading to normocytic anaemia 7.081Transfuse 2 -3 units initially Treat severe sepsis – ceftazidine and gentamicin 54yo female Post-operative normocytic anaemia 8.384No transfusionFeSO 4 Re-check Hb to ensure no further drop 73yo male Macrocyosis probably alcohol related with ? Varicael bleed Transfusion – Xmatch 6 units; Resuscitate Urgent OGD: May also have coagulpathy and thrombocytopaenia
Challenging Knowledge II Before attempting the skills in this module - List the steps you would take In order to cross match a patient for a blood transfusion To set up a blood transfusion List the common complications of a blood transfusion and their treatment.
Blood and Blood Product Transfusion You should be familiar with each of these blood products. What are their indications and the complications associated with them? Whole Blood Packed Cells Platelets Fresh Frozen Plasma (FFP) Cryoprecipitate
The Principle Aims of Blood Transfusion are to:- (1)Improve oxygen carrying capacity of blood. (2)Symptomatic improvement. (3) Reduce hypovolaemia. 1 UNIT of Blood should increase the Hb by approx.1g/dL. If no improvement or reduction in Hb – think about ongoing blood loss or destruction. You need treat the underlying cause.
Blood Transfusion Indications - I The Sanguis Study, 1994 No consensus on who, when, where and why to transfuse a patient A lot of variation in practice – dependent mainly on the individual clinician ordering the transfusion 'Strong suggestion that inappropriate use is widespread'
Indications for Blood Transfusion Acute Anaemia (1)Symptomatic hypovolaemia and blood loss. (2)Peri-operative – 'replacing losses' (3)Haemolysis (treat the underlying cause) (4)Severe, critical illness.
Blood Transfusion Indications - II Acute Anaemia Increase oxygen carrying capacity of blood - Young adults can tolerate 30 – 40% volume loss with adequate crystalloid replacement alone - Weiskopf et al (1988) – Euvolaemic anaemia in healthy volunteers (and patients) down to Hb ≥5g/dL (!) – No demonstrable inadequate tissue oxygenation - I.e. Only for symptomatic hypovolaemia
'Keep the Hb ≥ 10 g/ dL' (2) Peri -operative Much quoted by Surgeons still - 'Keep the Hb ≥ 10 g/ dL BUT Carson et al (1988); Stehling & Simon (1994) Patients tolerated Hb 8 – 10 g/dL No patients died with Hb ≥ 8g /dL and ≤ 500ml blood loss No data on morbidity ? Healing / recovery etc
Severe illness – Expensive Scare (3) Severe and critical illness Oxygen delivery is dependent on: (a) Cardiac output (c.o.) (b) Oxygen content of blood However there is very little change in C.O. until Hb ≤ 7 g/dL. Herbert et al, 1999 – recommended this was the level taken for transfusion in the critically ill unless other factors were present.
Recommendations for Transfusion Bracey et al, 1999 ≤ 9 g/dL – CABG operation ≤ 8 g/ dL – Symptomatic anaemia and blood loss ≤ 7g/dL – Critically ill (Herbert et al) But: on-going and further blood loss must be taken into consideration as must the clinical situation and co-morbidity!
Pale Mrs McPale – Hb 'Unmeasurable' Chronic Anaemia Transfuse according to - Symptoms - Co-morbidities - Level of Activity Correct underlying cause and deficiencies 'Beware the 'well patient' with the macrocytic anaemia, Hb of 2g/dL – 'Slowly down – Slowly up'; Remember their blood may be 'see through' but they are essentially euvolaemic. A large, rapid transfusion will cause fluid overload and pulmonary oedema.
Conclusions Acute Anaemia Treat Patient according to situation - Co-morbidities - Symptoms - Cause of the Anaemia - Severity and likelihood of re-bleed Red Cell Transfusion SHOULD not be solely used as a 'plasma expander' – but primarily as a method to increase oxygen carrying capacity.
Pre – Transfusion Considerations Does the patient need the transfusion? Does the patient want the transfusion? - Verbal consent - ? Soon to be written consent Cross match vs Group and Save? How many units to Cross? (As opposed to many rivers to cross (ho ho)) When to re-cross in active bleeding Local haematology policies
Does the patient need the transfusion? Yes: Symptomatic anaemia Significant blood loss Anaemia / severe illness Improving Oxygen capacity of the blood No: Asymptomatic Hb ≥ 8 g/dL 'Well' patient receiving alternative therapies – EPO or Iron 'Euvolaemic' Anaemia secondary to B12 and folate deficiencies
Does the patient want the transfusion? Consent - Recommended to obtain verbal consent from every patient; ?Soon to be written. Need to discuss: - Indication; Benefits - Risks - Infectious incidence HIV 1per 3x 10 6 HBV 1per2 x Non Infectious e.g. Transfusion reaction - Patient's right to refuse transfusion e.g. Jehovah's witnesses, has to be respected if decision made when competent. - Most hospitals now have Blood Transfusion nurse specialist to assist with these issues.
Requesting Blood and Blood Products Bureaucratic errors are the commonest cause of blood transfusion problems – DON'T BE A STASTISTIC! Requests will not (and should not) be processed if any of the following stages are missed or are wrong. (a) Request Form details (b) Blood bottle details (c) No patient wrist band or missed details on the band (If phlebotomist is taking the blood).
Write up the Blood Transfusion Cross match request using the form provided Mrs Kathy Lawrence is a 79yo woman with myelodysplasia. She has been re-admitted with a symptomatic anaemia, Hb 4.9 g/dl, MCV 87. Please write a request form for her cross match using the form provided. Hospital number ; DOB 13/09/24; Turner ward; Multiple transfusions over the last 6 months; Blood group A Rh +; No known antibodies; Four pregnancies
Patient Details required – apply within Patient Details required on form Full names DOB Hospital Number Location Blood Group (if known) Previous transfusion and obstetric history Transfusion details Reason for request; Present Hb (if known) Location, Date and Time of expected transfusion Date of request Type of blood (Packed cells, whole blood, G&S only); Number of units. Doctor Details Name, Bleep number and Signature of person requesting the blood LABELS ARE NEVER ALLOWED ON THE FORMS OR THE BOTTLES
Sample Collection – No magazines available Check patient details on wrist band vs form. Use Pink cross match bottle (In use nationally) Details required on Blood bottle - Full names of patient - DOB; Gender; Hospital number - Signature of person taking blood - Date and Location Take blood bottle down to the blood bank if required urgently – you will also meet the cross match team (essential when you need a favour) and where the blood fridge is situated. PATIENT LABELS WILL NOT BE ACCEPTED!
Setting up the Transfusion Units of blood are stored in the 'blood bank' fridge or theatre fridge. You will need all the patient's details prior to going to collect any blood products Check details of blood report form against unit of blood. [Do not accept any wrong or missing details] You will need to sign for the unit in blood bank register; The responsibility is therefore yours! Start transfusion within 30 minutes of blood being removed from the fridge. This picture is for those that have never seen a fridge!
The Ian Wright, Wright,Wright Rule The Right Blood, The Right Patient, The Right Time! Why can't you use this unit of blood unless you are a Vet?
Cross Match or Group and Save (G&S) Guides (particularly for major surgical procedures) are available in most hospitals. Most haematology labs can cross match blood in 20 minutes. Cross match when (a) Significant, on-going or potential significant blood loss (b) Severe symptomatic anaemia or illness
Prescribing Blood Transfusion Please write up the a four unit blood transfusion for Mrs Lawrence using the fluid chart supplied. The correct format is shown on the next slide. Why do we give frusemide? What is the slowest rate of transfusing a unit of blood?
DateCentral or peripheral line Type of Infusion Fluid Volume of Infusion Fluid (ml) Drug to be added Total dose in bag Infusion Rate Doctor's signature PBlood1 unit4 hours PBlood1 unit4 hours PFrusemideIV 40mgAfter second unit PBlood1 unit4 hours PBlood1 unit4 hours PFrusemideIV 40mgAfter fourth unit PN. Saline100mlTo flush the line 20 minutes Ward: TurnerHospital No: Consultant: FeatherName; Kathy Lawrence DOB: 13/09/24 Weight
Setting up a transfusion Prescribe Transfusion on IV chart - State units to be given - Rate of each unit (slowest approx 4 hours) - Give saline (100ml+) before (to keep cannula 'open') and after transfused units to 'wash through' the line. - Frusemide (40mg) is often given with each or every other unit (IV or PO) to stop potential fluid overload. Not required when patient is hypovolaemic - All patient details MUST be correctly charted.
Blood Transfusion It takes TWO to check details of blood unit Check details on the unit of blood against those written on the form against patient's wrist band. ALL MUST BE CORRECT! (Recent advance = bar code devices) DO NOT PUT UP UNITS WHICH YOU ARE NOT HAPPY ABOUT! Check any queries with the laboratory or the haematologist on-call.
Blood Transfusion - Procedure Introduce yourself to the patient Check patient understanding and ensure they are happy to receive blood transfusion Gain verbal consent Ensure patient has venous access – will need to site cannula if no access present! Check equipment – Correct unit of blood and blood giving set With a partner – check unit of blood details against transfusion slip Check patient details against blood unit. Puts on gloves Attach unit of blood to giving set and run through blood correctly Aseptically attach blood giving set to cannula; Secure the giving set and cannula with bandaging. Ensure blood is flowing and set at correct rate Inform nurses blood is running and to make sure routine observations are made.
Setting up the transfusion To set up a transfusion (1)Two people to check details (2)Blood transfusion report form; Unit(s) of blood (3)Patient with IV access (!) and wrist id band (4)Sterile blood giving set
Blood Transfusion - Acute Complications I ComplicationCauseIncidence / Likely timing with regard transfusion Treatment Acute Intravascular haemolysis ABO incompatibility (Commonest cause is administrative!) 1:6x10 5 Occurs within a few mls of starting transfusion (Mortality 10%) Shouldn't happen! STOP THE BLOOD! Supportive treatment Treat complications – ARF and DIC Febrile Non-haemolytic reactions Anti –Leucocyte Ig or Cytokines in platelet transfusions Commonest in patients receiving multiple transfusions or previously pregnant Becoming rarer because of leucocyte depletion in many transfusion practices. Occurs towards the end of or up to hours after transfusion Unpleasant – but not life threatening Paracetamol and cooling. UrticariaTransfusion contains plasma proteins or allergens causing an acute IgE mediated allergic response Occurs with plasma and platelet rather than red cell transfusions. 1 – 2% of all transfusions Peri-transfusion May occur recurrently Unpleasant – but not life threatening Anti-histamines – (can be given prophylactically in known patients) Infective shockBacterial contamination of transfused blood Rare; 1:5x 10 5 First 100mls of blood – ie early Often fatal! That of Septicaemia and shock – fluids, IV antibiotics AnaphylaxisAnti-IgA antibodies ?others Patients are often IgA deficient as well! Extremely rareLife threatening A.B.C / Crash team call IV / IM adrenaline, steroids, aHistamines, Oxygen Nebulisers.
Blood Transfusion - Acute Complications II Transfusion Related Acute Lung Injury (TRALI) RHS Rare; Non-cardiogenic Pulmonary oedema Caused by donor blood containing anti-Leucocyte antibodies Occurs at the start of the transfusion Can be life threatening Treat for (a) Acute transfusion reaction (b) Respiratory failure (ARDS), Shock and Pulmonary oedema (RHS – Rocking Horse Shit – Not Royal Horticultural Society) As Dorothy parker once said – 'You can lead a whore to culture but you can't make her think')
Blood Transfusion – Delayed Complications ComplicationCauseIncidence / TimingTreatment Delayed Red cell haemolysisRecipient IgG vs Red cell antigens Occurs in previously transfused or pregnant patients; Initial cross match will not contain IgG but subsequent cross matches should! 5 – 10 days after transfusion <1:500 red cell transfusions No treatment per se but Patient will receive less benefit from transfusion and once present they will cause problems for future transfusions Transfusion associated Graft versus Host disease (TA-GvHD) Immune mediated donor T- cell reaction (often occurs in immunodeficient patients) Fever, Rash, MOF, Pancytopaenia Rare 1:750,000 units of cellular blood components transfused 4 – 30 days after transfusion Usually fatal! Haematology specialist care required In susceptible recipients – blood is subjected to Gamma irradiation Post Transfusion Purpura Anti-Platelet antibodies (usually aHPA-1a) Immune medicated TCP Primarily during pregnancy RHS Rare days after transfusion Often severe TCP causing bleeding Use HPA-1a negative red cell and platelet transfusions or LDBlood High dose IV Immunoglobulins for 5 days 0.4g / kg Post Transfusion Viral Infection Virus (and other infective agents e.g. prions) undetected by UK screening system HIV <1: 3x 10 6 HBV and HCV < 1: 2 x 10 5 Counselling and specialist advice required Iron overloadMultiple transfusions One unit of blood contains 250mg of iron Only occurs after several years of blood transfusions e.g. Chronic haemolytic disease Desferrioxamine – increases iron excretion
Generic Management of Acute Transfusion Reaction Most 'reactions' occur within the first fifteen minutes of blood being started – this is the most important time for observations to be done. Do not hide the patient away during this time – let the nurses know transfusions are running and that they should do formal observations for the first fifteen minutes and then routinely. If a reaction occurs:- Stop the unit of blood being transfused! Ensure patient is clinically well and no other pathology is present (why are they having transfusion etc) - Treat the underlying cause of 'reaction'; Once patient is deemed OK:- Disconnect and take down entire transfusion giving set and blood unit. Maintain venous access with normal saline Check administrative details from transfusion forms and patient's wrist band Contact the haematology / transfusion lab and inform them you are returning the unit of blood for testing. Take bloods – Blood film, FBC, Cultures, Clotting, Cross match sample (U&Es) If blood transfusion is essential or serious reaction occurs need further advice from haematologist Nursing staff need to observe patient for signs of 'shock', DIC, acute renal failure Thus 'Regular' observations of BP, Pulse, T o C, Urine output
Re-cap of Multidimensional analysis Hopefully by now you will be familiar with using multidimensional analysis. I have included the example from module one. If you are confident using other methods this is fine but you must get the answers correct!
Dimensional Analysis Dimensional analysis is commonly used by chemistry and physics students to ensure they don't make basic calculation errors when using lots of values in an equation with different units; Each time one converts one unit to another we use a conversion factor, which we will call the dimensional analysis conversion factor (DACF) e.g 450g to kg – the DACF = 1000g / 1 kg Thus 450g / Xkg = 1000g / 1 Kg XKg = 450g x 1 Kg 1000g = Kg Dimensional analysis ensures that both sides of an equation are 'singing from the same hymn sheet'. I.e. The units on both sides are the same. By cancelling the units above and below the line, the units yu are left with on one side should equal those of the value you are seeking. If they don't match, you have mucked up somewhere! It will not ensure your maths is correct.
- Dr Michael Baker – a teacher with a similar outlook on education! Dimensional analysis for party planning… If you have ever had a party you have used dimensional analysis. The amount of beer (or soft drinks) and munchies you will need will depend on the number of people you expect. For 30 people you may estimate you need to go and buy 120 bottles of beer and 10 large pizzas (obviously not a medic party!) How did you guestimate these numbers? Here's the dimensional analysis. 4 bottles / person and 1/3 of a pizza per person 30 persons x (4 beers) = 120 beers person 30 persons x (0.333 pizza) = 10 pizzas person But should you buy beer in six packs or cases? – 1 case = 4 six packs = 24 Beers 120 beers x 1 six pack x 1case = 5 cases 6 Beers 4 six packs 1 case / 4 six packs = 5 cases / x six packs = 20 six packs
To calculate drip rates / transfusion rates Blood transfusions are run through specific giving sets with a filter included in the chamber and wide bore tubing. You can NOT run them through a normal giving set as without the filter the blood will coagulate. Likewise you should NOT run fluids such as saline and dextrose through a blood giving set unless it is during or after a blood transfusion.
To calculate drip rates / transfusion rates For any giving set the tubing will have its own drop factor. This is the number of drops in 1ml. The drop factor is written on the packaging and is dependent on the bore of the tubing. For reasons unbeknown to me the units of drop factor is gtt / minute. Common drop factors are 10, 15 and 20 gtt / min Paediatric drips commonly have a drop factor of 60 gtt /min Saline and Dextrose are commonly run through 10 gtt / min tubing whereas blood is commonly run through 20 gtt / minute tubing
To calculate drip rates / transfusion rates To calculate the drip rate (drops / minute) Drip Rate gtt = Volume to be infused (ml) x Drop Factor (gtt/ml) min Time (minutes) 1 unit of blood is approximately 400ml in volume E.g. A unit of blood is prescribed to run over 2 hours; The giving set has a drop factor of 20 gtt /ml. What is the drip rate (drops /min)? (See next slide for answer and calculation) The calculations used here are similar to those used for crystalloid transfusions – see module (4)
Example one – Calculate the Transfusion rate E.g. A unit of blood is prescribed to run over 4 hours; The giving set has a drop factor of 20 gtt /ml. What is the drip rate (drops /min) ? Drip rate = 400 ml x 20 gtt ; Drip Rate is drops / minute 4 hour 1ml Thus Drip Rate = 400ml x 20 gtt x 1 hour 4 hour 1 ml 60 minutes By multidimensional analysis units are correct (drops / minute) Drip Rate = 100 / 3 = 33 drops / minute Drop rate is rounded up or down to the nearest drop In the clinical setting to be able to count drops / minute it is sensible to have a number divisable by 4 - Thus you would set this drip at 32 drops per minute
Please try the following calculations – They should be included in your folder (1)A 71 yo man is receiving a blood transfusion after a hemicolectomy. The transfusion is set at 30 drops per minute with a giving set of 20 gtt / ml. The unit of blood is prescribed for 4 hours as he has grade 1 heart failure. Is the transfusion rate correct? (2) A 31 yo woman is having a blood transfusion after having a major upper GI bleed due to a peptic ulcer. The unit of blood is running through a giving set with a drop factor of 10 gtt/ ml. The rate of the infusion is set at 60 drops / minute. How long will it take the 6 units prescribed to run through assuming there is 5 minutes to change each unit?
A 71 yo man is receiving a blood transfusion after a hemicolectomy. The transfusion is set at 30 drops per minute with a giving set of 20 gtt / ml. The unit of blood is prescribed for 4 hours as he has grade 1 heart failure. Is the transfusion rate correct? Using Drip Rate = Volume to be Infused x Drop factor Time in minutes X gtt / min = 400ml x 20 gtt x 1 hour 4 Hr 1 ml 60 minutes The drip should be running at 33 gtt/ min – so it needs to be re-set.
A previously well 31 yo woman is having a blood transfusion after having a major upper GI bleed due to a peptic ulcer. The unit of blood is running through a giving set with a drop factor of 10 gtt/ ml. The rate of the infusion is set at 60 drops / minute. How long will it take the 6 units prescribed to run through assuming there is 5 minutes to change each unit? Using Drip Rate = Volume to be Infused x Drop factor Time in minutes 60 gtt / min = 400 ml x 10 gtt x 1 hour X hour 1 ml 60 minutes X hours = 4000 = 1.11 hours / unit 3600 Thus for 6 units = 1.11 x 6 = 6.67 hours Plus 5 minutes between units 1,2; 2,3; 3;4; 4,5; 5,6 = 25minutes = 0.42 hours Total transfusion (or confusion) = 7.1 hours
Converting drip rate (gtt /min) to ml /hour In high dependency areas caring for critically ill patients it may be necessary to know the infusion rate in ml/hour – this is important in setting infusion pumps and in calculating fluid balance. E.g. What is the transfusion rate in ml /hour of a blood transfusion being run at 40 drops / minute through a giving set with drop factor of 20 gtt / ml?
If there are 40 drops in one minute then in 1 hour 40 drops = X drops thus X = 40 x 60 = 2400 drops / hour 1 minute 60 minutes If the giving set has drop factor of 20 drops/ 1 ml 20 drops = 2400 drops thus Xml = 2400 = 120 ml / hour 1 mlX ml 20 Therefore one could set an infusion pump to deliver this volume or it can be factored into the fluid input /hour.
Calculate the Transfusion rate in ml/hour A 94 yo woman is receiving a 'slow blood transfusion for myelodysplasia. The unit of blood is being run at 60 drops / minute through a 20 gtt / ml giving set. Calculate the rate of the transfusion and comment on whether the rate is appropriate
Too Much – Too Quickly If there are 60 drops in one minute then in 1 hour 60 drops = X drops thus X = 30 x 60 = 3600 drops / hour 1 minute 60 minutes If the giving set has drop factor of 10 drops/ 1 ml 20 drops = 3600 drops thus Xml = 3600 = 180 ml / hour 1 mlX ml 20 Thus the unit of blood (400ml) will run through in 400 / 180 = 2.22 hours I.e. Too quickly for an 94 yo with myelodysplasia
Learning Outcomes At this point you should Have read and made notes regarding the 'who, why, where and when' of blood transfusion Be aware of the acute and chronic complications of transfusion Be aware of the steps regarding ordering and setting up a blood transfusion Be able to order a cross match for a patient Be able to prescribe a blood transfusion Be able to calculate the correct infusion rate in drops/min and ml / hour If you are unable to achieve all of these outcomes at this point you will need to continue to practice the skills and re-visit the webpages to refresh your knowledge
Recommended websites and References References to follow
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A Roth IRA is a tax-advantaged retirement account that allows you to build your nest egg using after-tax dollars. The Roth IRA was introduced in 1997 as an alternative to the traditional individual retirement account. The Internal Revenue Service places limitations on who can contribute to a Roth IRA, the amounts they may contribute, and when contributions can be made.
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In CREATE I &II the team at GT shepherded the emergence of technology that can be deployed in the home to enhance the health and well-being of older adults. An important next step is the ecological assessment of these technologies to translate science into practice. An ecological assessment is needed to have a complete understanding of technology acceptance, patterns of use, and to determine the benefits of technology outside of the laboratory environment. There is also a need for research to provide guidance for the design of future high-technologies such as cognitive prostheses and Collaborative Machine Assistants (CMAs). An additional goal of our research is to inform design of these technologies so that they can be successfully deployed with older adult populations. Our research program will involve two research projects and two collaborative projects and involves a three-pronged scientific approach: 1) tests within the ecology of use, systems whose design is a direct translation of CREATE's previous work;2) translational research that fosters the deployment of cognitive prostheses so they can by deployed within the time frame of CREATE III; and 3) assessment of forward technologies (CMAs) that have not been evaluated with older adult populations.
Aims of the proposed program are to: 1) facilitate linkages between older adults and family members;2) provide the scientific foundation necessary for effective cognitive protheses;and 3) provide the scientific foundation for effective human-intelligent agent interaction. Research project 1 focuses on cognitive prostheses and involves three studies. Study 1 will provide an in-depth understanding of memory failures and successes occurring in daily living environments and Studies 2 &3 will evaluate cognitive augmentation for prospective memory problems. Research project 2 will focus on CMAs and involves two studies (4 &5). Study 4 will assess perceptions of usefulness and general attitudes, beliefs, and knowledge about CMAs and Study 5 will manipulate characteristics of CMAs, such as design of feedback (cooperative vs. directive) and the "affect" of the intelligent agent, and assess interactions with the CMAs as a function of the age of the user. Collaborative projects will involve partnership with Intellihealth, a company at the forefront of providing technology for in-home use that can support older adults and their families. It will evaluate a family telecare system that supports social interaction and memory of older adults living at home. The second collaborative project will evaluate a planned expansion for this system, a medication reminder component.
Technologies hold potential benefits for enhancing the quality of life for older adults and enable them to live independently at home. Most older adults prefer to age-in-place. The results of this research program will advance the deployment of technologies in the home environment, support translation of fundamental scientific knowledge for design of deployable systems and guide the design of home technologies of the future.
|Kelly, Andrew John; Fausset, Cara Bailey; Rogers, Wendy et al. (2014) Responding to home maintenance challenge scenarios: the role of selection, optimization, and compensation in aging-in-place. J Appl Gerontol 33:1018-42
|Taha, Jessica; Sharit, Joseph; Czaja, Sara J (2014) The impact of numeracy ability and technology skills on older adults' performance of health management tasks using a patient portal. J Appl Gerontol 33:416-36
|Boot, Walter R; Stothart, Cary; Charness, Neil (2014) Improving the safety of aging road users: a mini-review. Gerontology 60:90-6
|Charness, Neil (2014) Utilizing technology to improve older adult health. Occup Ther Health Care 28:21-30
|Smarr, Cory-Ann; Mitzner, Tracy L; Beer, Jenay M et al. (2014) Domestic Robots for Older Adults: Attitudes, Preferences, and Potential. Int J Soc Robot 6:229-247
|Mitzner, Tracy L; Chen, Tiffany L; Kemp, Charles C et al. (2014) Identifying the Potential for Robotics to Assist Older Adults in Different Living Environments. Int J Soc Robot 6:213-227
|Stothart, Cary R; Simons, Daniel J; Boot, Walter R et al. (2014) Is the effect of aerobic exercise on cognition a placebo effect? PLoS One 9:e109557
|McBride, Sara E; Rogers, Wendy A; Fisk, Arthur D (2014) Understanding human management of automation errors. Theor Issues Ergon 15:545-577
|Fox, Mark C; Mitchum, Ainsley L (2013) A knowledge-based theory of rising scores on "culture-free" tests. J Exp Psychol Gen 142:979-1000
|Boron, Julie Blaskewicz; Rogers, Wendy A; Fisk, Arthur D (2013) Everyday memory strategies for medication adherence. Geriatr Nurs 34:395-401
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No new injury worries for Leeds ahead of clash with Sheffield Wednesday
Leeds head coach Garry Monk is expected to choose from an unchanged squad for the visit of promotion rivals Sheffield Wednesday.
Right-back Lewie Coyle, not included in the squad for last week's draw at Ipswich, is unavailable due to a foot injury sustained in training.
Left-back Charlie Taylor, out since mid-December with an Achilles injury, is not ready for match action after returning to full training this week.
Otherwise, Monk has no new injury or suspension worries, while skipper Liam Bridcutt,...


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Palaces of the Yi Kings
By RICHARD HALLORAN; RICHARD HALLORAN, a correspondent in The Times's Washington bureau, formerly covered Japan and Korea.
Published: September 17, 1989
THE ghosts of the Yi dynasty, whose kings ruled Korea from 1392 to 1910, still haunt the palaces of Seoul,those oases of serenity amid the incessant motion and noise of this vibrant city. But the tranquil halls and exquisite gardens, a refuge from the Hyundai cars and the purple and white buses that rumble like elephants through the streets, mask a past rife with court intrigue, betrayal and war.
The Yi (pronounced ee) kings who built the palaces in Seoul reigned over the most intellectual period in Korean history. In the capital then known as Hanyang, movable metal type was invented early in the 15th century. Shortly after, King Sejong fostered the spread of phonetic writing that made the Korean language easier to grasp than the Chinese ideographs in which it had been written.These innovations led to an outpouring of books on Confucian philosophy, history, art, medicine, music, agriculture, mathematics, astronomy and military science.
Palaces in Korea, like those in China and Japan, are not single buildings as in Europe but vast complexes with towering gates, imposing halls where the rulers received their ministers and generals in audience, lavish living quarters and lovely gardens sprinkled with pagodas. The palaces of Hanyang were modeled on those of China, with their tiled roofs and sweeping eaves, but were given a Korean touch with their exteriors left in subdued ocher reds or natural wood and their interiors decorated with intricate, bright ornamentation.
In the Kyongbok Palace, there were once 500 buildings within the walls. Today, the Ch'angdok Palace with its adjacent Piwon, or Secret Garden, that was reserved for the king and his women, covers 180 acres. Add the Ch'anggyong Palace, a detached palace next to Ch'angdok, and the Chongmyo Shrine, where tablets commemorating the Yi ancestors are kept, and the entire complex rivals the Forbidden City in Beijing and the Imperial Palaces in Kyoto, Japan.
The palaces of Seoul are the only ones remaining in Korea, this city having been the capital for so long. Another center of culture, however, is the city of Kyongju, in southeastern Korea, where the Silla dynasty flourished from 661 until 935. Kyongju today is the site of Buddhist temples and the tombs of kings that are being carefully excavated to yield the secrets and treasures of Silla. Between Silla and Yi, the Koryo period was filled with strife, the Mongol invasion and war.
The Seoul palaces, burned in war and partly rebuilt several times, are, not surprisingly, a source of national pride. On almost any given day, throngs of schoolchildren ranging from kindergarten through high school can be found there.
Everywhere in the palaces are signs in Korean intended to nurture the deep-seated animosity toward the Japanese who invaded the peninsula in the late 16th century (and were driven out after six years) and who occupied Korea from 1905 until 1945. Signs in English remind visitors of the Korean enmity. Perhaps the nearest analogy in the West is the Irish enmity for the English. Koreans now emulate the Japanese in economic development but in their hearts, as in Irish hearts, are dark broodings about their former colonial masters across a narrow sea.
Three of Seoul's four extant palaces are in the northern sector of the city, on the opposite side from the site of the Olympic Games a year ago, with their backs to the jagged, rocky mountains that once were a barrier against invaders from the north. As with most palaces in East Asia, they face south to ward off the evil spirits thought to come from the northeast and, in the bitter Korean winter, to capture the rays of the southern sun. The fourth palace, Toksu, is in the center of Seoul and is a pleasant place to stroll but lacks the size and grandeur of the others.
The northern palaces, which are landmarks known to everyone in Seoul, are within walking distance of one another and it is perhaps best to start with Kyongbok, the oldest. The palaces are open to the public from 9 A.M. to 6 P.M. from spring to fall and close an hour earlier in winter. The visitor might want to plan his trek around the times that Ch'angdok is open. Unlike the other palaces, in which one may wander at leisure, Ch'angdok can be seen only on a guided tour. English- speaking guides generally lead tours at 11:30 A.M., 1:30 and 3:30 P.M.
The Kyongbok Palace was built in 1392, a century before Columbus sailed to America, and was burned by the Japanese warlord Hideyoshi in 1592. It then lay in ruins until 1865 when it was rebuilt. Most of the palace buildings were torn down by the Japanese when they annexed Korea in 1910 and what remained was blocked from view by the Japanese capitol erected on the southern edge of the grounds in 1926. Kyongbok was again damaged during the Korean War (1950 to 1953) when American and South Korean forces fought twice with Chinese and North Korean troops over the city.
IN the 1960's, as South Korea got back on its feet, the Government began to restore Kyongbok. The main gate, called Kwangwha-mun, was reconstructed in front of the capitol in 1969 so that it would dominate a broad avenue through the center of the city - and hide the capitol built by the Japanese. Government offices were moved in 1983 to convert the capitol building to a museum, which was opened in 1986. Though the gate was reconstructed, much of the palace is original and the restoration retains the site's ancient atmosphere.


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Health, Self-Help, Religion & Spirituality, Buddhism, Other, SpiritualityFollow
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May all Beings be Happy
February 18th, 2007
Episode 32 of 400 episodes
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Michael St. Lawrence, Steve Johnson
If You're Not Out Selling, You're Being Outsold
Книгу можно купить в интернет-магазинах:
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ISBN: 0471191191Издательство: Wiley
"If You're Not Out Selling, You're Being Outsold is more than a 'how-to-sell' book. St. Lawrence and Johnson have approached the art of selling from a witty, entertaining, and inspirational view. The authors candidly recognize what ingredients are required for reaching success, and they have blueprinted a constructive approach that can apply to anyone, whether they are contemplating entering sales, or have made sales their career."—Nicholas D. Wolkonsky Director of Sales, High Volume Division, Western Region, ADT Security Services, Inc. "If You're Not Out Selling, You're Being Outsold is an inspiring book written by two professionals who actually do sell. I found the principles and techniques easy to follow and implement. I am buying copies of this book for all my sales managers."—Robert Coakley Divisional Director of Sales, Alamo Rent A Car, Inc. No matter what sort of business professional you are, you have to sell to succeed: make yourself heard, make your...
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NEC Display MultiSync P212-BK 21" LED LCD Monitor - 4:3 - 8 ms - High performance in a 4:3 display.The 21" MultiSync P212 utilizes a 1600x1200 long life IPS LCD panel to deliver consistent color all hours of the day. Powered by the NEC-designed SpectraView engine, the P212 offers accurate color and fully customizable presets to meet any color needs. In addition, the P212 includes a wide array of connectivity to work with both new and existing configurations.
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Joey Barton has moved a step closer to leaving Newcastle United today after Queens Park Rangers approached the midfield player over a possible transfer.
The Times understands that QPR contacted Newcastle out of courtesy to say they would be holding talks with Barton, although they do not require permission as he has been transfer listed.
Barton was told that he could leave St James's Park for no fee three weeks ago after criticising the Newcastle hierarchy's recruitment policy via Twitter.
However, the midfield player rejoined Alan Pardew's senior squad and has played in both Barclays Premier League games this season,


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- Price$1,399,999
- Beds4
- Baths4
- Sq. Ft.1,958
- Acres154.27
- Built1995
271001 Rge Road 44 in For Sale
Here sits your little slice of foothills heaven. Not only does this property feature full south and west mountain views, but it also has beautiful ravine views from the naturally rolling land. As soon as you open the door to your new home, pride of ownership is evident. There are beautiful hardwood floors through the living area, a raised formal dining room, office with California Closet built-ins, and a large laundry area with sink and half bathroom off the garage. The master bedroom has a large walk-in closet and relaxing master ensuite bathroom with shower and soaker tub to enjoy the picturesque views. Three more bedrooms, a partly finished exercise room, and two more bathrooms round out the living area, not to mention the huge basement family room. The family room also has a log lighter fireplace and a full wet bar area to entertain friends and family for the largest of occasions. The walk-out basement door from the family room leads to the professionally landscaped back yard with patio and firepit. There's in-floor heat in both basement and garage for even the coldest of winter days; a new concrete tile roof adds value and durability. Out your door you'll find everything to operate your horse or cattle operation. 4 corrals, 3 horse shelters, and 3 automatic waterers compliment the 32x32 ft enclosed UFA barn with overhang, tack room, one box stall, and water hydrant fed from well. Beside the barn is a 25x50m riding arena that will be the envy of any horse-riding friend. There is a 32x68ft shed to hold equipment. Your new home is 1 km off pavement and close to all amenities – 3 minutes from the Springview RV Park with fuel and grocery store, 8 minutes from downtown Cochrane, and 20 minutes from Calgary. Two titles being sold together make 154.27 acres total, 3 acres of that designated to residence and yard and 151.27 acres designated to cross fenced pasture land. Keep the 12.48 acre title or sell it as a new acreage and instantly make revenue off this transaction. GST is applicable on this property.
Bungalow listed in Rural Rockyview County at 271001 Rge Road 44
Essential Information
- Price$1,399,999
- Bedrooms4
- Bathrooms4.00
- Full Baths3
- Half Baths1
- Square Footage1,958
- Acres154.27
- Year Built1995
- TypeDetached
- Sub-TypeDetached
- StyleBungalow
- StatusActive
- FeaturesCeiling 9 ft., Deck, Fire Pit, No Smoking Home, Patio, Dog Run-Fenced In, Vaulted Ceiling, Wood Windows, Workshop, Wall Unit-Built-In
- Parking Spaces5
- ParkingDouble Garage Attached
- Site InfluencesFlat Site, Golf Nearby, Level Land, Low Maintenance Landscape, Schools, Shopping Nearby, View Mountain, Cross Fenced, No Through Road, Rolling Land, Ravine View, View
- ExteriorBrick, Stucco
- Exterior FeaturesFlat Site, Golf Nearby, Level Land, Low Maintenance Landscape, Schools, Shopping Nearby, View Mountain, Cross Fenced, No Through Road, Rolling Land, Ravine View, View
- RoofConcrete Tiles
- ConstructionWood Frame
- FoundationConcrete
Additional Information
- Days on Market45
Community Information
- Address271001 Rge Road 44
- AreaRural Rockyview County
- CityRural Rockyview County
- ProvinceAlberta
- Postal CodeT4C 1A7
- HeatingNatural Gas, Forced Air-1
- Has BasementYes
- BasementFully Finished
- FireplaceYes
- FireplacesWood With Log Lighter
School Information
- DistrictRocky View Schools
Listing Details
- Listing OfficeCentury 21 Summit Realty
Disclaimer: Information herein deemed reliable but not guaranteed by CREB®.
Listing information last updated on February 24th, 2017 at 5:30am MST.


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Supply Chain Design and Management
Strategic and Tactical Perspectives
By (author) Manish Govil Jean-Marie Proth
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Supply Chain Design and Management by Manish Govil
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Book DetailsISBN: 9780122941511
(229mm x 152mm x 18mm)
Pages: 246
Imprint: Academic Press Inc
Publisher: Elsevier Science Publishing Co Inc
Publish Date: 1-Feb-2002
Country of Publication: United States
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- Home
- The Prime Minister
- About Rwanda
- The Government
- Media
- Publications
- Address
The Cabinet Meeting started by wishing His Excellency the President of the Republic of Rwanda, Paul KAGAME, Merry Christmas and Happy New Year 2017 and He wished Members of Cabinet New Year 2017 full of peace and prosperity.
1. His Excellency the President of the Republic of Rwanda informed the Cabinet Meeting that He granted pardons for girls and women tried and convicted of abortion, which the Court has given final judgment and children under 16 tried and convicted and their judgment became res judicata. All of them are 62.
2. The Cabinet Meeting approved the Ministerial Order granting release on parole to 814 convicts who meet the requirements provided for by Law No 30/2013 of 24/05/2013 relating to the code of criminal procedure.
3. The Cabinet Meeting approved minutes of previous Cabinet Meeting held on 11/11/2016.
4. The Cabinet Meeting approved the National Capacity Development Policy, Strategy and Implementation Plan.
5. The Cabinet Meeting approved the Rwanda National Water Supply Policy and Strategy.
6. The Cabinet Meeting approved the Rwanda National Sanitation Policy and Strategy.
7. The Cabinet Meeting approved the National Policy against Delinquency and its implementation plan 2016/17 – 2020/2021.
8. The Cabinet Meeting approved the proposal for the establishment of a Rehabilitation Center at Nyamagabe District.
9. The Cabinet Meeting approved the proposed revised Medical Tariff for Medical Insurance Scheme namely RAMA and Private Health Insurances as follows:
10. The Cabinet Meeting approved the following Draft Laws:
11. The Cabinet Meeting approved the following Orders:
12. The Cabinet Meeting approved the agrément of the following persons to represent their respective countries to Rwanda as Ambassadors:
1) Mr. KIM EUNG-JOONG, of the Republic of South Korea, with residence in Kigali.
2) Mr. SEYED MORTEZA MORTAZAVI, of Islamic Republic of Iran, with residence in Kampala, Uganda.
3) Ms. ELIZABETH TAYLOR, of the Republic of Columbia, with residence in Nairobi, Kenya.
13. The Cabinet Meeting proposed the candidacies of Mr. MUHUMUZA Richard for the post of Judge in the Supreme Court and Mr. MUTANGANA Bosco for the post of Prosecutor General, both candidates are subject to approval by the Senate.
14. The Cabinet Meeting made the following appointments
a) In Ministry of Health
b) In MINAFFET
c) In MININFRA
d) In the Capacity Development and Employment Services Board (CESB)
e) Provinces Executive Secretaries
f) Mr. KAMANZI Emmanuel: Member of Board of Directors/Rusumo Power Company Ltd
g) In Ministry of Youth and Information Communication Technology/ MYICT
h) In Ministry of Justice/MINIJUST
i) In Rwanda Biomedical Center/RBC
j) In Rwanda Public Procurement Authority/RPPA
k) In Public Service Commission/PSC
15. In AoB:
a) The Minister of Justice/Attorney General informed the Cabinet Meeting that the International Human Rights Day will be celebrated on 10/12/2016 under the theme: "Stand up for someone's rights today and promote child's rights to education." In Rwanda, celebrations will be held in Rubavu District and shall be preceded by a sensitization campaign on human rights from 4th to 10th December 2016.
b) The Minister of Health informed the Cabinet Meeting that Rwanda will host the 37th Global Fund Board Meeting in Kigali from 3rd to 4th May 2017.
c) The Minister of Local Government informed the Cabinet Meeting that in a bid to ensure smooth Presidential elections in 2017, the National Electoral Commission has prepared a calendar for the planned preparatory activities.
d) The Minister of Youth & ICT informed the Cabinet Meeting that from December 6th -13th 2016, "Itorero Urunana rw'Urungano" is taking place in Gabiro Combat and Training Camp.
e) The Minister of Trade, Industry and East African Community Affairs informed the Cabinet Meeting that the Second Made in Rwanda Exhibition is scheduled to take place in Kigali, at Gikondo Expo Grounds from 14th December, 2016 till the 20th December 2016.
f) The Minister of State/MINEDUC in charge of Primary and Secondary Education informed the Cabinet Meeting that the 2017 school calendar year is composed of 39 weeks divided into the three terms as follows:
This Statement was signed by
Stella Ford MUGABO
The Minister in Charge of Cabinet Affairs


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The Lame Duck quacks that the FBI and CIA have both said the Russians did it. LIE! The CIA propaganda machine claims they did. The FBI crime solvers say they didn't.
There again, "at this point, what difference does it make?" Because WHOEVER exposed the sordid goings-on at the rotten heart of the Clinton campaign did ordinary Americans a REALLY big favor!


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2017 NBA New Year's Resolutions - Western ConferenceNBA teams always have room for improvement. Here are 2017 New Year's resolutions for the Western Conference.
5 Bold NBA Predictions For 2017The NBA saw more than its fair share of surprises in 2016. What will happen in 2017?
NBA 2016-17 Season Preview: Western ConferenceThe 2016-17 NBA season tips off October 25. Preview the Western Conference elite, contenders, on the rise and rebuilding teams.
4-19-16 Mitch Evans Experience Sound Bite of The Night And ScoreboardMitch plays Stan Van Dundy audio talking about refs on Lebron James and Mitch goes around the sports world in the scoreboard segment
2016 NBA Playoffs: Western Conference PreviewThe Warriors dominated the NBA regular season, with the Spurs close behind. Can Curry and company take the West again?
Hardaway, Bench Lead Hawks To Fifth Straight Win, 109-97 Over RocketsAfter being missing in action for the first half of the season, Tim Hardaway Jr. is beginning to show why the Atlanta Hawks were willing to trade a first-round draft pick for him. Hardaway played only four games and served two terms in the D-League before he worked his way into the rotation in January. He's since become a steady contributor and Saturday scored 20 points for the second consecutive game and played a key role in the team's fifth straight win...
Top 5 Surprises Of The Early NBA 2015-16 SeasonWe are 20 games into the NBA season. Let's take a look at the Top 5 surprises so far this year. 76ers? Kobe? McHale? Warriors? There's a lot to talk about so far...
Zinno: "The 19k people at Philips Arena Tuesday night saw how the Hawks will play in the post-season!"
Listen: Steve Holman on the Call (Atlanta Hawks 104 – Houston Rockets 96)
Looking Forward to NBA All Star Weekend - Pt. 2
Rick Kamla's NBA Power Rankings Top 5 Through Two Weeks
Top 3 Things We Learned In NBA Week 2


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Free ESL Interview English Lesson - If you could change one thing about your personality, what would it be and why?
Hanap Leksiyon
Leksyong Pakikipag-usap
Mahahalagang Pananalita ng English
Leksyong Regular
Leksyong Pang-Bisnis
Leksyong Pang-Interbiyew
Leksyong Paglakbay
Parapong Idyoma
Topikong Espesyal
Indeks ng Buong Leksyon
Leksyong Pakikinig
Karaniwang Leksyong Pakikinig
Leksyong Intermediyang Pakikinig
Pangunahing Leksyong Pakikinig
Karagdagang Leksyong Inglis
Leksyong Pagbibigkas
Gramatikang Impormasyon
Intonasyon at Bilis
5 Alintuntunin para Leksyong Pakikipag-usap
If you could change one thing about your personality, what would it be and why?
If you could change one thing about your personality, what would it be and why?
This question is another variation to the weakness question. You can provide a similar type of question unless it is the same person asking them. To answer this question, think of a person you respect and the trait they have that you really like. I used to have a manager that was very patient and explained things very carefully. I really liked this trait, so I'm going to provide the long answer by using this example. But first, let's look at some short answers.
Short Answers
I get easily frustrated at people who don't work very hard. But I know people have different work styles and different work habits. So if I could change something, I would like to be more understanding.
I have high expectations and I have these expectations on others. I think if I was more understanding, I could help other workers improve instead of being disappointed.
I would like to be more of a risk taker. I always do my work and complete it at an exceptional level, but sometimes taking a risk can make the work even better. I'm working on this by thinking the issue through and weighing the pros and cons.
I would like to be more of an extrovert. I'm a little quiet and a little closer to the introvert side. I would like to change this because I would appear more friendly.
Long Answer
I wish I was more patient with people. I remember a manager I had a couple of years ago. He was very patient with everyone. Even workers that were not that smart and failed to understand a concept to perform the job. I remember thinking how can this person who can't understand this concept continue to work here. My manager took a different approach. He was understanding of this worker and explained the concept in a different way. He even explained how to view problems from a different perspective. That helped this worker and in time that worker became a strong contributor. So if I could change one thing about me, I would like to be more patient and understanding. I'm taking the steps to change for the better by remembering the actions of my past manager whenever I'm in a similar situation.
This is a little long, but if you can speak smoothly, it shows off your communication skills. Also, the content of the answer is not that bad. They want a personality problem, and this answer is showing impatience while indicating that you understand difficult concepts easily. It also shows that you are working on correcting the bad behavior.
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sa pamamagitan ng TalkEnglish Offline Version at sanayin ang sarili sa 8,000 audio files at mahigit 800 pahinang leksyon! At pagkatapos maaari ka nang makapag-aral ng walang koneksyon sa Internet at mapakikinggan mo ito gamit ng iyong MP3 player kahit kailan. Pumunta sa
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Protective film for vehicles with parking aid plus and headlight washer system
Art.-No. 8T1071316H
Reliable protection against damage to your paintwork. The crystal-clear adhesive film retains the paint's brilliance without altering the lines of the vehicle. It is flexible, pliable, durable and UV-resistant. The robust and virtually invisible paintwork protective film is safe for use in car washes as well as with high-pressure cleaners. Notes - Suitable for vehicles with parking aid plus and with headlight washer system - Installation by qualified personnel/specialist workshop is recommended. This image shows a visualisation of the protective film on an Audi A3.
- RS 5 Coupé 2013
- RS 5 Cabriolet 2013
*MSRP = Manufacturer's suggested retail price


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Deli Roast Beef in a Slow Cooker
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Dance. Urban. UK
This week Chris Brown's been shooting the music video for 'New Flame' while Nicki Minaj continues to tease the release of 'Anaconda' - check out all the picture you shouldn't have missed this week.
Picture 18 of 43
He wrote: "Love is life & life is love and we're so excited for another GIFT from up above
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Take CableTV.com's Advice and Make DIRECTV Your Next TV Service Provider
We want to help you find the best television services available in your area, which is why we've compiled results from a number of independent consumer surveys—to make it easy for you to find the best cable companies and other TV services for your home. Between all of the satellite TV and cable companies in North Bonneville, WA, these surveys show that DIRECTV is considered to be the best TV service provider for local consumers.
Price is just one factor to consider when looking for the best cable company in North Bonneville, WA. There are other aspects to consider when selecting your TV provider, including channel choices and availability. Although most major networks are available everywhere, small networks and local channels aren't. In fact, TV packages in North Bonneville may offer a completely different set of channels from similar packages in just the next town over. Whether you're hoping to catch your favorite shows or the upcoming or Seattle Seahawks game, it's always important to know your package's channel selection. That's why CableTV.com has compiled information on the highest rated providers available in North Bonneville—so you can quickly identify the companies that have what you're looking for.
Customer support and dependability of service are two of the qualities that CableTV.com uses to evaluate providers and make recommendations. This ensures that you're getting the best TV provider for your needs. So, when you rely on our recommendations while choosing a cable company in North Bonneville, WA, you can rest assured that you've signed up for a company that delivers both reliable service and friendly help when you need it.


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Recent Members
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Honoring Our Heroes
This area is dedicated to our alumni that have served or are serving in our armed forces!
Lost Class Rings
Have you lost your Hanahan High School class ring? Have you found someone's class ring? Visit our Hawks lost class ring page to search for your class ring or post information about a found ring.
Honored Military Alumni
Adam (Troy) Evans Class of 1979
Army, 15 Years Commo chief, Supply Sgt., served in Turkey, Korea, Germany and Desert Shield/Storm Retired 100% disabled
Brian K. Salvo Class of 2000
Army, 12 Years .
David Wiggins Class of 1963
Navy, 20+ Years Retired after 28 years in Submarine Service
Diane Donaldson Wright Class of 1974
Navy, 12 Years Naval Nurse Corps
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Navy, 10 Years deployed in operation desert storm on board the USS Paul F Foster DD-964
Kirsis Cabrera Class of 1998
National Guard, 11 Years Served 8 years on active duty, currently in the South Carolina Army National Guard.
Linda Lee Outcault Class of 1982
Army, 20+ Years Air Force Crew Chief, Army & Army reserves, Army National Guard. Served in Iraq
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Air Force, 9 Years Three tours in Desert Storm
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Read and submit stories about our classmates from Hanahan High School, post achievements and news about our alumni, and post photos of our fellow Hawks.
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Angelina's New School
Written by
Illustrated by
Part of the Angelina Ballerina Series
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Podcast: Holidays - unauthorised absence, cover and contact
Various issues can arise when employees take holiday. An employee may fail to return to work when due, or the employer may not have granted the leave in the first place. We discuss how employers can limit and deal with this type of unauthorised absence, as well as the steps that employers can take if employees fail to make arrangements for vital work to be covered in their absence. We also consider if it is reasonable for employers to contact employees while they are on holiday.
In addition to listening to the audio, you can download the podcast transcript.
Presenter Laura Merrylees is joined by Clio Springer. Edited and produced by Claire Scullin.
Holidays: unauthorised absence, cover and contact
19 August 2016


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Hotfrog Canada provides information regarding Famous Players in Mississauga ON. Famous Players is located at 309 Rathburn Rd W, Mississauga ON L5B 4C1 and provides Social services. Contact them on (905) 279-9027 or by visiting them on their website http://www.cineplex.com/Theatres/TheatreDetails/Cineplex-Cinemas-Mississauga-formerly-Coliseum-Mississauga-.aspx.
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Upholstered curved chair backs9/26
We are looking at making some arm and side chairs that have an upholstered seat and back, wood arms and legs. The curved back of the chair is upholstered front and back.
This is something new for us and I had originally thought of laying up veneer and vacuum bagging the backs over the form but then wondered if other would go about this with two layers of bending ply?
Im having trouble locating what I would consider to be cost effective construction grade veneer to lay up.
Sorry for the simple question but any input is appreciated.
Chairs are tricky to make well. We have the same chairmaker for the last 32 years and he cuts all the parts from solid wood. If I understand you are looking to make a traditional dining chair with a curve on the back. We use the bandsaw and pin router to make the curves and use webbing to create the back surface for foam and fabric.
As I mentioned, in the chairs we are planning the entire back is upholstered.
Link goes to LH but no image. If it is a formed plywood back we do a jig and glue up 1/8" then veneer over it all or add a solid top if it is a rounded top. The more radical Italian curved chairs I won't do
We will try this.
We would build a jig and glue up 3/8" bending ply then veneer it all.
Actually i would not veneer it as it is fully upholstered.
Thanks Glen,
Well, if you just use two layers of bending ply, you only have two thin veneers running horizontally where you really need to connect for strength.
Rather than having to make a substantial plug to form around inside of the bag, I like to use a big envelope that contains the laminates after the epoxy is rolled on, then bend the whole bag around the form which is outside the bag, and can be made very easily out of cheap ply or sheet goods. Then it only has to be strong enough to support against the springbuck of the sum of parts, which is not much, and only needs hand pressure to hold against the form, while another person clamps some 2x4s long enough to hang off the ends. Once the vacuum is pulled, they aren't even needed, since the pressure on both sides of the bag is so great it will hold the shape even without the form, so long as you don't loose the vacuum.
Bending ply comes in 4x8 and 8x4, with the face veneer running opposite on each option. Shops that edge glue door skins can supply you with single ply faces whatever size you require.
That is what I would do, but I don't' do big volumes.


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New York Times bestselling author Karen Robards continues her penchant for "fantastic storytelling" (RT Book Reviews) with this next heart-pumping romantic suspense novel, the tale of a brilliant ornithologist trapped on the remote Attu Island in Alaska, fighting for her life - and that of a handsome stranger - before they're swallowed up in darkness forever.
©2016 Karen Robards (P)2016 Brilliance Audio, all rights reserved.
There are no listener reviews for this title yet.
"Narrator Ruined the Story"
No. It's always unfortunate when a narrator ruins a good story. This happens to be one of those times. The female lead character came off as whiny and annoying, the inflections and constant breathlessness at the end of each sentence made me cringe. The male lead came off as one dimensional and harsh.
No. I actually had to force myself to finish listening to it.
I loved the plot but will need to read a hard copy version to get a better view of the characters. Both main characters came off as incredibly annoying because of the way the narrator read them. I always enjoy Karen's books, but this one turned me off because of the narration (and an over excessive use of adjectives describing everything down to a rock...)
"Not one of her better ones."
it seemed to drag a little bit. Storyline was predictable. heroin was a little bit whiny.
"Do authors get to pick the narrator?"
If I had read this book, the voice in my head would not have made the female character sound like such a breathless timid drama queen. The story was good. I liked the fact it was set in Attu where my grandfather was stationed in WWII. The characters were good if one only listened to the words and not the voice inflection of the narrator.
The story was pretty good - though I don't know if people that cold and that much on guard could have sex. My main problem was with the narrator mispronouncing ornithologist.
"Okay story, narrator issues"
Could not get past narrators glaringly obvious mispronunciation of words! One Example, OrNIthologist, not OrINthologist!
"The narrator"
I couldn't finish the book because the narrator voice is too whining when the character is in fear. The story itself what I have listen too is interesting. So I will definitely buy the actual book to read.
just couldn't get into it, not what I was wanting. No no no no no
"Horrible audio ."
The recording, mixing and audio was horrible, it paused often, cut out parts, made the story very hard to follow. I wouldn't waste a credit. I suggest the author find someone to redo this reading. it was just bad all around. I don't even know the end of the story because it got that bad. waste of credit. I give the story a 3 only because I'm sure the author didn't know just how bad her work has been mutilated by the recording and sound engineering.
"Loved it!"
Robards has always been a fav and this did not disappoint- great adventure, romance, emotion, and humor all in one!
The performance was awesome too- the reader was great with the accents and it really pulled me in to the story.
"it was a good story"
this was a good story I read half of the book on my own before I downloaded the app because I just couldn't get enough of the story once I downloaded it was able to listen to it on my way to work it allowed me to finish the story much quicker
You really do feel the cold and lethargy in this book as the narration is very slow and tired-sounding. The initial plane crash is quite harrowing and if you are phobic, might be a bit too disturbing.
Overall an OK listen as a doctor and a mysterious man who may or may not be the enemy, evade others on a remote island.
Report Inappropriate Content
If you find this review inappropriate and think it should be removed from our site, let us know. This report will be reviewed by Audible and we will take appropriate action.


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2010 BMW X6 M Recalls
RepairPal Expert Overview on October 20, 2011
On vehicles equipped with an 8 or 12 cylinder turbocharged engine, the circuit board for the electric water pump may overheat. This could lead to an electrical fire under the hood.
RepairPal Expert Overview on March 30, 2010
Incorrect installation of the windshield can weaken the stability of the roof in a roll-over type crash.


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Home › Forums › Feedback and Suggestions › Ship Parts on Horizon
This topic contains 4 replies, has 3 voices, and was last updated by Fenix 1 month, 2 weeks ago.
Not sure if this has been mentioned yet (Also sorry if this is the wrong place to be posting this) But while building, some parts disappeared, only to reappear super far away. As I turn my ship, these parts seem to be attached to it, just at an incredibly far distance. I added a wing and engine that disappeared, so now I'm not sure how much they may be affecting my flight patterns and physics being so far away. Is there a way to remove these? I really don't want to remake my entire ship, haha!
(Specific screenshot is foggy, but I can confirm these are parts from my ship)
EDIT: So turns out they are still registered on the ship, in the place I put them, however they appear to be far off. By destroying the item far away, they reappear on the ship. I had duplicate items as I had replaced them earlier on.
It's a bug, I've encountered it as well. Someone reported in the 5.1 bug thread too.
Ah alright! Also for some reason, I don't have access to the bug thread… tried initially posting there but couldn't.
I've had a similar bug, but it involves when I move things around on my ship, they disappear from view/interaction until I relog.
@erigorn, contact Bossa via the support section to let them know – anyone in the playtest should have access to the alpha forum.
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Valley Fever
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We are ideally located for easy access to the slopes, yet only a short walk from lively bars, shops and restaurants .
Valley Fever Chamonix Ski Chalets are equipped with roaring log fires, hot tubs & saunas, en-suite bathrooms, open plan living and dining areas, UK TV, DVD, WIFI throughout, a games console and more…..
If you're looking for an amazing chalet experience, excellent service and delicious food, then Valley Fever is the place for you!
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If you're looking for an amazing chalet experience with excellent service and sublime food, then Valley Fever is the place for you!
If you're looking for world class skiing, excellent service, &
sublime food come to our beautiful chalet with roaring log fire &
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Gas. Groceries. Routine expenses. You count on your debit and credit cards more than ever these days. With so many everyday expenses, you need an everyday card that works hard to save you money. That's why we offer you one of the lowest Platinum credit card rates available and rewards incentives on both credit and debit cards. At USECU, member savings are in the cards.
Tips for Preventing 'ATM Skimming'
A form of debit and credit card fraud called 'ATM skimming' continues to be a method of stealing information from unsuspecting cardholders. Fraudsters insert or affix hidden electronics onto ATM machines to steal the personal information stored on a debit or credit card, and record the owner's PIN number to access cash in the member's account.
It is important that you are aware about how to keep your debit and credit card information and PIN number safe while using ATMs.
Here are three tips to help you avoid becoming a victim of ATM skimming:
Protect Your PIN
Hidden cameras, false "overlay" keyboards, and other methods are often used to steal your PIN. Covering the keyboard as you enter your PIN is a simple way to help avoid theft. Never give your PIN to anyone, and do not use any ATM with a card reader that appears altered.
Observe The ATM
Devices added to the exterior are often taped for quick removal – jiggling the keyboard or insert device may tell you it is loose. This is one way of capturing your personal data. Highly trafficked ATMs and those with security or cameras may be less likely to be tampered with. Uncertain? We recommend that you go to a different ATM or gas pump. If you notice something wrong, contact the credit union directly.
Check Your Balances Frequently
Checking your balances through online banking is the easiest way to watch your funds. Whether you suspect anything unusual or not, monitoring your account activity regularly allows you to recognize unusual activity quickly and report it to the credit union. Timely reporting may also limit your personal liability. Use the contact number on the back of your debit or credit card to report any fraudulent withdrawals and request your card be reissued.


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2-Pocket Literature Display (Stand-Up or Wall-Mount)
Estimated shipping date: Today (Click for more details)
Order by 1pm ET today for same-day shipping.
This two-tier clear literature display is excellent for tracts, pamphlets, trifolds and other items up to 4" x 9". Overall dimensions are 4 3/8" wide x 8 1/4" tall x 4 1/4" deep. Versatile design can stand on a desk, or easily be mounted on a wall.


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The Sparkle Horse
- Telephone 0141 562 3175
- Bar open Sun–Tue noon–11pm; Wed–Sat noon–midnight
- Food served Mon–Sun noon–10pm
- Pre-theatre times Mon–Fri noon–4pm (all day Tue/Wed)
- Average price £12.50 (Veg £9.75); £12.50 (evening meal)
- Pre-theatre price £12.50 (Veg £9.75)
- Website thesparklehorse.com
A neighbourhood bar where people in bands go for drinks, great value food and lively conversation when they found they've accidentally grown up.
The 2016/17 edition of The List's Eating & Drinking Guide is out now – only £5.95 (+p&p).
This review is taken from the current (2016) edition.
To be with friends in the Sparkle Horse, among the chatter after work on a Friday, is to feel like you're exactly where you should be. With its dark embossed walls, red couches, and somehow endearingly dated toilets, this place has the kind of atmosphere that chains desperately try to manufacture, but fail. It manages to be kid and dog friendly – without the danger of either tripping you on the way back from the bar – and there's a range of entertainment, from the ridiculously popular Monday quiz to the slightly chaotic baby disco. Good honest pub food or modern Scottish awaits if you climb the stairs to the restaurant area. Order the halloumi with a honey mustard dressing, or a portion of chips, and watch them vanish as your dining companions all steal one. The burgers are also a favourite, and taste better thanks to an unobtrusive soundtrack of indie and Americana.
- High point: £5/£6 menu a bargain (certain days/times)
- Low point: Brownie a little underwhelming
- Notable dish: Pan fried fillet of sea bass served on a bed of Lyonnaise potatoes and red pepper pesto
- Provides: Vegetarian options (at least ¼ main courses), Children's portions, Children's high chairs, Wheelchair access, Pre-theatre menu, Outdoor tables, Free wi-fi
- Music on stereo: Indie, alt country, Americana
- Capacity: 80
- Largest group: 25
- Open since: Dec 2012
- Number of wines sold by the glass: 11
- House wine: £14.95 per bottle
Event times
There are 2 events at this location
Sorted by title / date & time
Glasgow Knit 'n Stitch
Welcome to the Glasgow Knit 'n Stitch Group. We sit, we knit, we crochet, we stitch, we spin, we chat, we laugh, we eat & drink in venues all over Glasgow. Why not check out our Pages link to find out more about us? Membership: FREE. Sponsored by "Old Maiden Aunt Yarns", Studio 99B, Main Street, West Kilbride, KA23…
Tue 21 Feb
Prices to be confirmed / 0141 562 3175
Come and Knit in the West End
Tue 7 Mar
Prices to be confirmed / 0141 562 3175
Come and Knit in the West End
Tue 21 Mar
Prices to be confirmed / 0141 562 3175
Come and Knit in the West End
Round The World In 80 Books
Do you want to be part of a book group that is friendly, informal and accessible? Everyone is welcome at our new group. We are going to read translations of non-English books and hopefully immerse ourselves in a bit of foreign culture at the same time. Please contact us with any questions and feel free to pop in to our…
Thu 23 Feb
Prices to be confirmed / 0141 562 3175
- 19:00 – 22:00 Round The World In 80 Books The Sparkle Horse


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Virginia Rodrigues Sol Negro- Fantastic !!
I heard this album on an old crap quality mp3 disc..
It is such a fantastic album that I have just bought all three Virginia Rodrigues cd's.
If you dont listen to it all then at least check out
'Negrume da Noite' which is actually track 1 on the album... superb
Album encoded by Nero, VBR top quality.
Virginia Rodrigues - 'Nos' is also uploaded
If you like it buy the disc and support the artist, I got mine here quite cheap..
...note, the site actually appears to run through amazon.com
read more on Virginia Rodrigues here...
Dusta at 2005-04-26 01:51 CET:
Dusta at 2005-04-26 02:07 CET:
JerryZarga at 2008-02-21 15:47 CET:
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