text:
Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients
DOI: 10.1186/cc11880
© Helbok et al.; licensee BioMed Central Ltd. 2012
Received: 5 September 2012
Accepted: 23 November 2012
Published: 27 November 2012
Daily interruption of sedation (IS) has been implemented in 30 to 40% of intensive care units worldwide and may improve outcome in medical intensive care patients. Little is known about the benefit of IS in acutely brain-injured patients.
This prospective observational study was performed in a neuroscience intensive care unit in a tertiary-care academic center. Twenty consecutive severely brain-injured patients with multimodal neuromonitoring were analyzed for levels of brain lactate, pyruvate and glucose, intracranial pressure (ICP), cerebral perfusion pressure (CPP) and brain tissue oxygen tension (PbtO2) during IS trials.
Of the 82 trial days, 54 IS-trials were performed as interruption of sedation and analgesics were not considered safe on 28 days (34%). An increase in the FOUR Score (Full Outline of UnResponsiveness score) was observed in 50% of IS-trials by a median of three (two to four) points. Detection of a new neurologic deficit occurred in one trial (2%), and in one-third of IS-trials the trial had to be stopped due to an ICP-crisis (> 20 mmHg), agitation or systemic desaturation. In IS-trials that had to be aborted, a significant increase in ICP and decrease in PbtO2 (P < 0.05), including 67% with critical values of PbtO2 < 20 mmHg, a tendency to brain metabolic distress (P < 0.07) was observed.
Interruption of sedation revealed new relevant clinical information in only one trial and a large number of trials could not be performed or had to be stopped due to safety issues. Weighing pros and cons of IS-trials in patients with acute brain injury seems important as related side effects may overcome the clinical benefit.
Titrating sedatives and analgesics to achieve the right balance between deep sedation and wakefulness and to ameliorate patients' comfort in the intensive care unit (ICU) is an integral part of critical care [1]. Over-sedation can lead to prolonged duration of mechanical ventilation and ICU stay and increase the incidence of secondary complications, including nosocomial infections and delirium.
Daily interruption of sedation trials (IS-trials) have been implemented in many surgical and medical ICUs after randomized controlled trials demonstrated that IS decreased the duration of mechanical ventilation, shortened the hospital stay and may, in combination with spontaneous breathing trials, improve outcome in medical intensive care patients [2–6]. Another important issue of IS-trials is that the amount of sedatives and analgesics could also be reduced [2, 3]; however, the result of a recent meta-analysis of five randomized controlled trials comparing IS with no interruption in 699 critically ill patients challenges previous findings as a reduction in duration of mechanical ventilation, length of ICU stay or mortality could not be confirmed [7].
IS-trials in patients with acute brain injury are not well studied and the only case series, including 12 patients with traumatic brain injury (TBI) and 9 subarachnoid hemorrhage (SAH) patients, showed that the risk of elevated intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) is evident during these trials [8, 9]. Cerebral hypoperfusion and raised ICP may result in an imbalance of energy supply and demand especially for the injured brain and, therefore, aggravate the risk for metabolic distress and brain tissue hypoxia [10–16]. These potential side-effects of IS-trials have not been investigated so far and may limit their clinical benefit in severely brain injured patients. We hypothesized that IS-trials may be harmful for these patients and examined the effects of IS-trials on brain hemodynamic changes, brain tissue oxygen tension and metabolism using multimodal neuromonitoring devices in patients with acute brain injury.
Materials and methods
Between March 2009 and June 2010, 20 consecutive patients with acute brain injury were admitted to the neurological-ICU (NICU) at Columbia University Medical Center and underwent brain multimodality monitoring according to our institutional protocol. At the time monitoring was started, all patients had a Glasgow Coma Scale ≤ 8. In this prospective observational study, we investigated the effect of interruption of sedatives and analgesics on hemodynamic and brain metabolic changes. All interruption in sedation trials were conducted as part of the standard of care in the Neuro-ICU; therefore, consent was not necessary. Data were collected as part of an ongoing prospective database approved by the Institutional Review Board at Columbia University, New York.
Intracranial monitoring
Multimodality monitoring included at least ICP, cerebral microdialysis, and brain tissue oxygen tension (PbtO2) measurement and was initiated if (1) it was unlikely that the patient gains consciousness within the following 48 hours, and (2) the patient had a high probability to survive for the next 48 hours. Technical details on probe location, and practical aspects of neuromonitoring have been previously reported and are briefly summarized here [10, 11, 17]. A CMA-70 microdialysis catheter (CMA/MicrodialysisTM, Stockholm, Sweden), a flexible polarographic Licox Clark-type probe (Licox GMBHTM, Kiel, Germany; Integra-NeurosciencesTM) and a parenchymal ICP monitoring device (Integra-NeurosciencesTM, Plainsborough, NJ, USA) were inserted at the bedside, fixed with a triple-lumen bolt via a frontal approach into the hemisphere deemed at greatest risk for secondary injury (that is, perihematomal or pericontusional tissue, or the ipsilateral anterior watershed zone in lateralized SAH), or in the right frontal lobe in patients with diffuse injury. The location in the white matter was confirmed by brain CT scan immediately after the procedure. Brain metabolic parameters included glucose, pyruvate and lactate concentrations and were analyzed hourly (CMA-600; CMA/MicrodialysisTM).
Clinical management
Patient care for subarachnoid and intracerebral hemorrhage and TBI conformed to guidelines established by the American Heart Association and the Brain Trauma Foundation [18–20]. In general, hemodynamic and fluid management was targeted to maintain CPP ≥ 60 mmHg, and ICP < 20 mmHg. Adequate sedation and analgesia was performed with a combination of dexmedetomidine, midazolame, propofol and fentanyl. Fever was aggressively treated using intravascular (Celsius-Control-SystemTM, Innercool Therapies, Inc., San Diego, CA, USA) or surface cooling (Arctic-Sun Cooling-SystemTM, Medivance Inc., Louisville, CO, USA) devices. None of the patients were cooled during the IS-trial. Shivering was assessed using the Bedside Shivering Assessment Scale (BSAS) and graded from 0 to 3 points (0 = no shivering noted on palpation of the masseter, neck or chest wall; 1 = shivering localized to the neck and/or thorax only; 2 = shivering involves gross movement of the upper extremities (in addition to neck and thorax) and; 3 = shivering involves gross movements of the trunk and upper and lower extremities) [21]. Treatment of shivering included acetaminophen, buspirone and skin counter warming with forced air at 43°C and magnesium, meperidine and/or dexmedetomidine were used when primary measures failed [21, 22].
The goal of the sedation-analgesic regimen in the Neuro-ICU is to utilize the minimal amount of drugs necessary to adequately maintain a safe environment for ventilation, cerebral and systemic hemodynamics while also maximizing the ability to track changes in the neurological examination. Every patient was assessed daily by the treating neurointensivists (JC, SM, KL, NB) for IS-trial eligibility. Interruption was not attempted if one of the following conditions was present: severe hemodynamic instability, ICP > 18 mmHg and the use of sedatives as a primary treatment for ongoing elevated ICP. Other safety concerns included sedative infusions for active seizures, escalating sedative doses due to ongoing agitation or respiratory distress, and evidence of active myocardial ischemia within the last 24 hours. Patients who were eligible underwent interruption of all sedatives and analgesics.
Patients passed the IS-trial if they tolerated sedative interruption for at least 30 minutes (maximum 60 minutes) until awake without exhibiting failure criteria. Patients were monitored by the intensive-care staff or study personnel during the whole trial time. No change was made in fraction of inspired oxygen (FIO2) or positive end-expiratory pressure (PEEP) during the trial. Trained study personnel did neurological assessments, including the Glascow Coma Score (GCS) and FOUR Score, at baseline and after the 60-minute trial or before sedatives and analgesics had to be restarted [23].
Patients failed the IS-trial if they developed sustained anxiety, agitation or pain defined by clinical and cardiopulmonary stress and/or a respiratory rate of more than 35 breaths-per-minute (bpm) for > 5 minutes, an SpO2 < 88% for > 5 minutes, ICP > 20 mmHg and/or CPP < 50 mmHg for > 5 minutes, an acute cardiac dysrhythmia, or ≥ 2 signs of respiratory distress, including tachycardia (> 130 bpm), bradycardia (< 50 bpm), use of accessory muscles, abdominal paradox, diaphoresis or marked dyspnoea. When patients failed an IS-trial, sedatives and analgesics were restarted at half the previous dose and titrated to the desired level of sedation. Microdialysis probes were analyzed, per protocol, before medication was stopped, and in a 60-minute interval thereafter by the ICU staff nurse.
Data acquisition
The Solar-8000i system utilizing the General Electric Medical Systems Information Technologies' Unity Network® (Milwaukee, WI 53223, USA) was used to capture physiological data. A high resolution data acquisition system (BedmasterEX, Excel Medical Electronics, Jupiter, FL, USA) using the open architecture of the Unity Network® automatically acquired vital sign, alarm and waveform data from all the patient monitoring devices in the NICU. Digital data were acquired every five seconds and recorded in a SQL-database. Waveform data were stored at a resolution of 240 Hz in binary files. The LICOX and brain metabolism data were incorporated into the data acquisition system utilizing the communications (COM) port on the device and is plugged into a serial-to-TCP/IP interface device (Equinox ESP-8, Avocent, Sunrise, FL, USA). Physiological variables including heart rate (HR), arterial blood pressure, respiratory rate (RR), and oxygen saturation (SpO2) were continuously monitored in all patients.
Statistical analysis
Statistical analysis of pooled data was performed using Mann-Whitney-U, Student-t- Test for continuous variables and chi-square test for categorical variables as appropriate. RR, HR, mean arterial pressure (MAP), CPP and PbtO2 measurements were averaged every 15 minutes and time-locked to the IS-trial. Data are expressed as mean (± SD) or median (IQR) unless otherwise indicated. Time series data were analyzed using a multivariable general linear model (GLM). The model was extended by generalized estimating equations (GEE) using an autoregressor of the first order (AR-1) for model estimation of the data correlation structure of repeated observations within-subjects. Least significant difference (LSD) post-hoc comparisons of the estimated marginal means were used to assess differences in outcome variables over time. All statistical analyses were performed using SPSS 19 software (SPSS Inc., Chicago, IL, USA). Differences were considered significant at P < 0.05.
Baseline characteristics (N = 20)
Demographics and past medical history
Age, y
47 (34 to 56)
Gender (female)
9 (45)
14 (70)
2 (10)
4 (20)
Admission neurological examination
Admission GCS
8 (5 to 14)
Admission Hunt-Hess grade
5 (4 to 5)
1 and 2
2 (10)
3 (15)
8 (40)
Admission physiologic variables
APACHE physiologic score
15 (6 to 23)
Systolic blood pressure, mmHg
134 (116 to 160)
Days to Monitoring
2 (1 to 4)
Days with Monitoring
9 (6 to 13)
18 (10 to 26)
Hospital LOS
27 (18 to 37)
Discharge modified Rankin Scale
5 (4 to 5)
< = 3
3 (15)
3 (15)
9 (45)
Hospital mortality
5 (25)
Intervention and neurological assessment
IS-trial and hemodynamic changes
Average values of HR, RR, MAP and CPP at baseline, during the trial and two hours after restart of sedation are shown in Figure 1B-E. All parameters significantly increased from baseline (P < 0.001) without discriminating completed trials from interventions where sedation had to be restarted early (P > 0.6). Heart rate increased from 73 ± 4 bpm to a maximum of 97 ± 6 bpm, respiratory rate from 18 ± 2 to 30 ± 3/minute, MAP from 103 ± 5 to 117 ± 6 mmHg, and CPP 93 ± 5 to 111 ± 6 mmHg (P < 0.001, respectively). ICP was below 15 mmHg in all patients at baseline and remained stable in patients where the trial was completed. In patients where the trial had to be stopped early, ICP increased from a baseline of 12 ± 2 to 22 ± 6 mmHg (P < 0.05) (Figure 1F). No further increase in ICP was observed when sedation was restarted.
IS-trial and changes in brain tissue oxygen tension and cerebral metabolism
Brain tissue oxygen tension was 28 ± 2 mmHg at baseline and significantly decreased to 19 ± 2 mmHg in patients who developed one of the trial failure criteria (P < 0.05) (Figure 2C). In all of these trials a reduction of PbtO2 compared to baseline was observed, and in 67% brain tissue hypoxia (PbtO2 < 20 mmHg) occurred (Figure 2D). PbtO2 did not decrease below 15 mmHg in any patient. In patients who completed the IS-trial, a slight increase in PbtO2 (P = 0.07) was observed. In these trials PbtO2 was positively correlated with CPP (r = 0.54, P < 0.01).
Shivering (BSAS > 0) was observed in half of the trials and more commonly occurred in patients who failed the IS-trial (77% versus 43%, P < 0.05) (Figure 2E) [21].
In the present study we evaluated the effect of interruption of sedatives and analgesics on neurologic assessment, hemodynamic changes, brain metabolism and brain tissue oxygen tension in acutely brain injured patients. Our main findings were that IS-trials were not attempted on one-third of eligible days due to safety concerns, and that one-third of performed trials had to be stopped due to a critical increase in ICP and impending brain tissue hypoxia. All IS-trials were associated with cardiopulmonary stress, and detection of a new neurological deficit that led to a change in management occurred in only one trial (2%).
It is important to weigh pros and cons of IS-trials in patients with acute brain injury. Spontaneous awakening trials have been considered safe in medical and surgical ICU patients, but have not been validated for NICU patients [2–6]. In a recent meta-analysis, including 699 critically ill patients, daily sedation interruption was not associated with a reduction in duration of mechanical ventilation, length of ICU stay or mortality, and the authors call for more evidence before IS-trials should be recommended [7]. This may especially hold true for acutely brain injured patients, where an imbalance of energy supply and demand is common and additional stress may result in cerebral metabolic distress and brain tissue hypoxia [10–16]. We observed a sympathetic stress response with increased heart rate, respiratory rate and MAP during all IS-trials, which is in line with a recent report showing an excess of endogenous catecholamines and corticoids during neurologic wake-up tests [24]. Of interest is the observed effect of IS-trials on cerebral oxygen balance. PbtO2 increased in patients where the IS-trial could be completed with a positive correlation of PbtO2 and CPP, which may be explained by increased oxygen delivery without excessive energy consumption [25]. In patients who failed the trial, we observed a decrease in PbtO2 to critical values (< 20 mmHg) in 67% of IS-trials. In parallel, elevation in ICP was observed, which may increase the demand of oxygen and, therefore, decrease brain tissue oxygen tension. Normalization of PbtO2 after ICP decreased to normal values supports this hypothesis. Increased systemic oxygen utilization may also result in low brain PbtO2 levels, which is supported by the observation of systemic desaturation in 5 of 18 trials that had to be aborted and the notification of shivering during IS-trials, as noted by the BSAS-score [21]. The BSAS-score increased by two points, reflecting shivering with involvement of the neck, thorax and gross movement of the upper extremities [21], which was common in patients who failed the IS-trial. Shivering can trigger massive increases in systemic resting energy expenditure, and oxygen consumption [21, 22], and can potentially increase the risk of brain tissue hypoxia [16]. Therefore, shivering should be effectively treated by pharmacological and non-pharmacological means [26].
A marked increase in ICP and critical decrease in CPP has been previously described in TBI and SAH patients during neurologic wake up trials [8]. Similarly, we found that elevated ICP was the most often reported failure criteria in our trials. Restarting sedation resulted in an ICP decrease to normal values without the need for additional osmotherapy.
Patients who failed the trial had a trend towards higher LPR and lower brain glucose at trial start and during the observation period. This reflects that these patients were already more prone to brain metabolic distress at trial start, which may be a valuable safety consideration of IS-trials in critically ill neurologic patients. Anaerobic metabolism and mitochondrial dysfunction is common after severe head injury and associated with the initial trauma, increased ICP, global cerebral edema after SAH, focal or generalized brain edema, fever, seizures and others [10–16]. Recently, derangement in neuronal signal processing and energy metabolism potentially leading to sustained neuronal depolarization and depression of brain electrical activity have been described after SAH and TBI [27, 28]. In these conditions of deranged cerebral metabolism, the human brain may be more vulnerable to systemic and cerebral stress. It is important to mention that ICP increases and PbtO2 decreases did not result in brain metabolic changes in our patients, most likely due to the short duration of these episodes as all of these parameters were predefined as trial-failure criteria. Without online cerebral hemodynamic and brain oxygenation values IS-trials may result in prolonged episodes of elevated ICP or brain tissue hypoxia which are associated with anaerobic brain metabolism and poor outcome [11, 12, 29]. For further comparative studies, monitoring ICP and PbtO2 during IS-trials seems important, whereas microdialysis parameters seem to discriminate at baseline without adding further information during IS-trials.
One of the major rationales in the benefit of daily awakening trials is the additional information gained from a reliable clinical assessment. An increase in GCS and the FOUR score was observed in half of our patients. Evidence of a new focal neurologic deficit was found in only one SAH patient with known cerebral vasospasm who developed motor weakness of the lower limb. Repeated intra-arterial verapamil application resulted in increased perfusion and prevented cerebral infarction.
With limited clinical benefit of IS-trials in NICU patients, a sedation algorithm guided by commonly used sedation scales may be sufficient. However, the problem with this approach is that we still lack validated sedation scales to guide the neurointensivist in the management of acutely brain injured patients. At the end of each IS-trial, sedatives and analgesics were restarted at half the previous dose and titrated to the desired level of sedation. We believe that this strategy is important to prevent over-sedation of our NICU patients, which is a strong predictor for delirium and prolonged ICU stay. We used a fairly advanced sedation regimen, including dexmedetomidine, on our patients which may not be standard in other NICUs, which may have contributed to our findings and also explain differences to positive trials on medical patients [2–6].
Several potential weaknesses of this study deserve mention. The sample size is small and the population heterogeneous; however, a subanalysis, including SAH patients only, did not change our findings. Still, a potential selection bias limits generalizability of our data to all patients with severe brain injury since only poor grade patients that fulfill the inclusion criteria outlined in the methods section underwent multimodal neuromonitoring (that is, GCS < 8). One may argue that hemodynamic deterioration during IS-trials should be expected in this selective patient population; however, these are the patients with highest risk for secondary brain damage (that is, delayed cerebral ischemia (DCI)) where a proper clinical exam may uncover deterioration early. In one-third of our trials, critical ICP elevation was observed even after a specialized clinician considered the patient's condition as safe. Another point why our results should not be generalized is that IS-trials were limited to the neuromonitoring time and we may have missed important trial days. Neuromonitoring was started at Day 2 after ictus and the initial 48 hours may even be more critical for sedation interruption, even resulting in a higher number of side effects and safety concerns than described in this study. By increasing the sample size we would have been able to better describe a hemodynamic and clinical profile of patients where IS-trials are at high risk for being aborted. Another potential bias in this study is the large number of days when IS-trials were not attempted due to weekend days, or where the intervention was not considered safe. We do not know how these patients would have performed; however, based on our results, it is very likely that patients who were excluded from the trial due to hemodynamic or cerebral hemodynamic abnormalities would have deteriorated further during the trial. Another limitation is that we did not measure cerebral blood flow (CBF) and the status of cerebral autoregulation in all patients, however, observed an increase in respiratory rate in all patients. Hyperventilation is associated with cerebral vasoconstriction and decreased CBF and limited energy supply to the brain (oxygen and glucose delivery).
Interruption of sedation revealed new relevant clinical information in only one trial. A large number of trials could not be performed or had to be stopped due to safety issues. Although serious brain metabolic changes were not observed, related side effects may overcome clinical benefit in severely brain injured patients and the information gained by multimodal neuromonitoring can be used to safely conduct IS-trials in certain patients and disease states. Contrarily, long-term benefits of IS-trials in selected patients with severe brain injury may still prove beneficial. Future studies should evaluate the ability of advanced neuromonitoring techniques to determine patients most suitable for daily sedation interruption.
Key messages
Daily interruption of sedation (IS-trials) is considered safe in medical intensive care patients and associated with improved outcome.
Little is known about the benefit of IS-trials in acutely brain-injured patients.
IS-trials were associated with cardiopulmonary distress and brain tissue hypoxia and ICP crisis (one-third) in acutely brain injured patients.
Weighing pros and cons of IS-trials in patients with acute brain injury seems important.
autoregressor of the first order
Bedside Shivering Assessment Scale
- bpm:
cerebral blood flow
cerebral perfusion pressure
delayed cerebral ischemia
- FiO2:
fraction of inspired oxygen
- FOUR score:
Full Outline of UnResponsiveness score
Gasgow Coma Scale
generalized estimating equations
general linear model
heart rate
interruption of sedation
intracranial pressure
intensive care unit
interquartile range
lactate-pyruvate ratio
mean arterial pressure
- PbtO2:
brain tissue oxygen tension
positive end-expiratory pressure
respiratory rate
subarachnoid hemorrhage
standard deviation
- SpO2:
oxygen saturation
traumatic brain injury.
We thank the attending physicians, fellows and nurses of the Division of Neurocritical Care, Department of Neurology/Neurolsurgery, Columbia University Medical Center for their overall support of this project.
This study was supported in part by a Grant-in-Aid (9750432N) from the American Heart Association to Dr. Mayer.
Authors' Affiliations
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This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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Is to educate the masses about the actual truth. Not media hype to increase ratings. Discriminatory treatment of sex offenders should not be promoted or tolerated.
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Actual accounts of legalized discrimination.
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CUI Global, Inc. (NASDAQ:CUI) today announced it will participate in two upcoming investor conferences.
Craig-Hallum Alpha Select Conference in New York on Wednesday, November 16.
William Clough, chairman, president and chief executive officer, and Daniel Ford, chief financial officer, are scheduled to present at 2:50 PM ET and will host one-on-one meetings throughout the day.
Southwest IDEAS Conference in Dallas, TX on Thursday, November 17.
Clough and Ford are scheduled to present at 2:20 PM CT and will host one-on-one meetings throughout the day.
Story by ProactiveInvestors


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Surfside One Bed & Breakfast
No prices found through our partners. Please contact the business directly or check some of our recommended alternatives.
Travel Blogs from Whangamata
Landed OK
... and then we dropped in on the supermarket for some fruit, and liquor store for some wine. Emptied the car and had a sort out, and drank iced and fruity Sauvignon. We walked the few minutes down the road to the place with the most tempting menu. We had a glass each of Sauvignon and ordered a prawn and scallop and orange salad for 'er, and for me a 'hamburger' of smoked bacon and scallops, with frites, which were both so different on the palate and so delicious. There was a pretty ...
The Emperor's New Beach
... water. The water is supposedly so hot you need the seawater to wash in just to cool it off enough for you to comfortably sit in it. It was a cloudy, but warmish day when we went to the Hot Water beach, and it didn't take long to figure out where it was. The beach was deserted except for a small half court sized patch packed with people. As we got closer we saw quite a few people sitting in their holes enjoying the waters. We found an abandoned hole ...
Waiheke Island and the Coromandel Peninsula
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Farewell to the Phipps' and fun at Waihi Beach
... salt comes out of Kiwi salt shakers really quickly, along with tomato sauce from Kiwi sauce bottles.
After brekkie, we all went for a walk down the main street of Tauranga, which is only two streets from their home. Harrison wanted to buy Rio 2 movie, and was convinced it was out there somewhere in a shop. So we pounded the pavement looking for a suitable department store. Donna also had designs on a new red handbag, but only managed to find really ...
What a stunning coastline!
... news from the last few days. On Thursday we took the coastal road to Whitianga where we had arranged to stay in a motel for a night. The motels in New Zealand are really lovely, most are kept to a high standard and are much better than a lot of UK B&Bs! We got a lost again leaving Auckland; the road signs are terrible in NZ they are not very well signposted or are signposted at the last minute not leaving you enough time to work out which way to go! The coastal ...
Other places to stay in Whangamata
Pacific View B&B125 Pacific View Drive, Whangamata | B&Bfrom $164


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Historical photos of Rockville Centre
Originally inhabited by the Rockaway Indians, the Village of Rockville Centre was officially incorporated in 1893. It had a population of about 24,000 people in 2012, according to the U.S. Census Bureau.
Newsday.com now uses Facebook for our comment boards. Please read our guidelines and connect your Facebook account to comment.


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The Group Travel Leader | Group Tour and Travel Destinations, Attractions & MoreWhere in the World: Historic Homes
The Group Travel Leader
Published April 17, 2014
Washington Cedar Planked Salmon
Group Game: Presidential Puzzlers
It's personal in Friday Harbor
Check out the latest digital edition of our magazine!
© 2017 The Group Travel Leader, Inc. All rights reserved. Website by Cabedge - an Atiba Company


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FX Hotel Suzhou Guanqian
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How has this motel rated in the past?
- Suites
- Restaurant
- Free High-Speed Internet
- Room service
- Free parking
Photos of FX Hotel Suzhou Guanqian
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TripAdvisor Reviews FX Hotel Suzhou Guanqian
Travel Blogs from Suzhou
First stop for the day was near the only portion of the original ancient wall that surrounded Suzhou. A short walk to where we boarded boat for our cruise along the large canal and then through the smaller canals for which Suzhou was known as the "Venice of the east".
Suzhou is a network of canals and bridges with ...
Nanshan Temple and Canal Trip
We went back to Casa Zoe's for breakfast after moving from the Kempinski Hotel back to the Gran Park Hotel for work tomorrow. We then went to visit the Nanshan Temple, and walked around a market area, a bit like Confucius Temple area in Nanjing with small shops and stalls.
We then took a lovely boat trip down the Grand Canal (which we have been on in Hangzhou also), stopping off at a hand-made brick museum. Another lovely day.
Mt Lingshan Scenic Area
... area, we got a taxi out to the Lingshan Scenic Park area, with a large detour as the roads were blocked with military for some reason, and arrived at the park about midday. We could see the large bronze Buddha statue (the largest bronze Buddha statue in the world at 88m) in the distance, and followed the path walking past the Grand Screen Wall; the Altar of Buddha's Footprints; Nine Dragons Bathing Sakyamuni; Buddha's ...
... park as it was meant to be really beautiful. However when we eventually got there I was horrified to discover that the price to get in was 90 yuan! So after flinching, umming and ahhing, Katrin, Madeline and I decided that we would give the park a miss and meet Morgan and Verity who had money to burn at the train station. While we could've gone in, I really didn't want to pay that much money for a park when id already seen a lot of them in Beijing (for a quarter of ...
Gardens, Worms & Gondolas
... fish into the hold of the boat -- gross or ingenious, take your pick. We could not believe what we were seeing.
This was a very picturesque little town and we did a little shopping. We bought Brennan an ice cream cone, a 1/2 dozen tangerines for the road and a gourd flute. Brennan had at least a dozen people take his picture with them -- maybe the only Caucasian kid they would see in 2014!
It was now late afternoon and we had a 1-1/2 to 2 ...


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Thanks, Loarie. One of these days I will start figuring out how to ID birds.
You've certainly got herps down - any chance you can help me find a rubber boa one of these days? Now that ken-ichi's found one I'm starting to feel left out!
Can I come too?? :)
Yes, and yes.
The data quality assessment is a summary of an observation's accuracy. All
observations start as "casual" grade, and become
"needs ID" when
Observations become "research grade" when
Observations will revert to "casual" if the above conditions aren't met or the community agrees
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New Radiohead Track: "These Are My Twisted Words" [MP3]
The new Radiohead song is so good that we feel like it's our duty as music fans to pass it along to anyone who needs it. We're pretty sure it's okay to do this. If not, sorry. We'll take it down when they ask.
It sounds like a lost Can track to us, Like maybe a spiritual child of "Vitamin C." Maybe.
Download the new Radiohead track, "These Are My Twisted Words," after the jump. It's perfect for a Sunday morning.
The download arrived with this missive:
Upcoming Events
Preston Smith
TicketsTue., Feb. 28, 8:00pm
Iris Williams
TicketsTue., Feb. 28, 8:30pm
Birds of Chicago
TicketsTue., Feb. 28, 9:30pm
Open Hand, Hoax Party
TicketsWed., Mar. 1, 7:00pm
Social Distortion, Paul Cauthen, Jade Jackson
TicketsWed., Mar. 1, 7:00pm
iiiiiiiiii iiiiiiiiiiii
iiiiiii radiohead - these are my twisted words iiiiiii
iiiiiii iiiiiii
iiii artist.......radiohead iiii
iiii title........these are my twisted words iiii
iiii label........?????????? iiii
iiii cat.nr.......????????? iiii
iiii style........'dificult' iiii
iiii nr of tracks.1 iiii
iiii total length..5.32 iiii
iiii audio source.CD Advance iiii
iiii encoder......LAME 3.93 iiii
iiii quality......320kbps/44.1kHz/Joint Stereo iiii
iiii size.........12,70 MB iiii
iiii ripper.......sca[GG]er iiii
iiii rls.date.....2009-08-17 iiii
Thom York in LA: two recent snapshots from radiohead.com
iiii i just wanted to reassure readers iiii
iiii that following representations iiii
iiii seeking confirmation iiii
iiii that before your very eyes iiii
iiii behind the wall of ice iiii
iiii that the box is not under threat iiii
iiii however they are set to remove iiii
iiii other boxes iiii
iiii in fact i have the list in front of me iiii
iiii i went to a briefing on their plans iiii
iiii and challenged them to tell me iiii
iiiii exactly what the cost would be iiiiiii
iiiiii iiiiiiii
iiiiiii they spoke in broad terms iiiiiiiiii
iiiiiiiiiii we're looking for: talented puppeteers iiiiiiiiiii
iiiiiiiiii worms, disgruntled executives, sacked flies iiiiiiiiii
iiiiiiii genres: doomcore, folktronica, ukf iiiiiiii
Note: this is a big file (12 mb), but that's because it's 320 kbps. It's worth it; "Twisted Words" is a dynamic song, and deserves the space on your hard drive.
Radiohead - These Are My Twisted Words (MP3)
UPDATE: The Quietus seems to have cracked some sort of code that we were too dim to, and believes there's a whole new EP, called Wall of Ice, imminent. (via The Daily Swarm)
UPDATE: It's official: this track is available for free download at Radiohead's W.A.S.T.E. store.
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Epistle Reading
Document Actions
St. Paul's First Letter to the Corinthians 9:19-27
Prokeimenon. Mode 1.
Psalm 26.1,2
The Lord is my light and my savior.
Verse: The Lord is the defender of my life.
BRETHREN, though I am free from all men, I have made myself a slave to all, that I might win the more. To the Jews I became as a Jew, in order to win Jews; to those under the law I became as one under the law - though not being myself under the law - that I might win those under the law. To those outside the law I became as one outside the law - not being without law toward God but under the law of Christ - that I might win those outside the law. To the weak I became weak, that I might win the weak. I have become all things to all men, that I might by all means save some. I do it all for the sake of the gospel, that I may share in its blessings. Do you not know that in a race all the runners compete, but only one receives the prize? So run that you may obtain it. Every athlete exercises self-control in all things. They do it to receive a perishable wreath, but we an imperishable. Well, I do not run aimlessly, I do not box as one beating the air; but I pommel my body and subdue it, lest after preaching to others I myself should be disqualified.
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The English text of the Acts of the Apostles and Epistles is based on the Revised Standard Version from "The Apostolos" by Holy Cross Press, Brookline, MA.
The Revised Standard Version of the Bible is copyrighted 1946, 1952, 1971, and 1973 by the Division of Christian Education of the National Council of the Churches of Christ in the U.S.A. and used by permission.


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Rago Response: This could have been mislabeled in production. Errors do happen! Rago specifications are copied by many designers and they know this for a fact.
Marlene from Delray Beach
Rago Response:
Try the Rago 6207
this should not roll. The Rago 513 and Spanx are very different garments.
Chris from Houston
HerRoom Response: This is a brand new product by Rago. It would not have been possible for you to have ordered this previously.
Trish from NJ


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Angels Afterthoughts: Props for Butcher
* Angels pitching coach Mike Butcher has taken a lot heat for the performance of the pitching staff over the past couple of years, but he got a nice shout-out from C.J. Wilson tonight.
Wilson had given up two runs on four hits and three walks in his first four innings. He said that's when he talked to Butcher about what he felt was going wrong.
"He gave me a mechanical adjustment," Wilson said. "That made a big difference and everything synched up from there."
Wilson has been sizzling lately – going 7-1 with a 1.96 ERA over his past eight starts – but this one was not nearly as neat as some of his recent outings.
"C.J. had trouble with first-pitch strikes, had trouble with ball-strike ratio, but he seemed to make pitches to get out of jams or minimize damage," Manager Mike Scioscia said.
* Earlier this month in Seattle, the Mariners played an exaggerated shift to the right side against Hank Conger, which Conger said no team had ever done before.
Tonight, the A's did it to him when he came to bat with no one in the sixth inning. Conger yanked a ground ball to the right side, but it still got through for a hit.
* J.B. Shuck had a rough week, failing to come through in clutch situations in the late innings on Monday and Tuesday, but he helped make up for it with a good night tonight.
Shuck beat out the back end of a potential double play in the third, which extended the inning long enough for him to score the game's first run on an Albert Pujols single.
In the fifth, with the Angels trying to stay out of a double play, Shuck executed a hit-and-run perfectly, singling into center field and sending Erick Aybar from first to third, which sparked a four-run inning.
In the sixth, Shuck was called on to sacrifice and he bunted so perfectly that he beat it out for a hit.
Shuck also made a nice throw to the plate in the fourth inning, but Chris Young just beat catcher Hank Conger's tag.
* J.C. Gutierrez gave up one hit in a scoreless inning in his Angels debut. He was hitting 95 mph with his fastball.
"Nice delivery, power arm," Scioscia said. "The ball came out hot. Hopefully he'll have a good role in our bullpen."
* Josh Hamilton returned to the lineup after missing three days with a sore right ankle. Hamilton's at-bats were nothing special – he went 1 for 5 with an RBI and hit into a double play – but Scioscia was encouraged to see that the ankle didn't affect his running. Hamilton scored from first on Mark Trumbo's double in the fifth.
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Wayne 68787 Real Estate
Wayne is located in Nebraska. Wayne, Nebraska 68787has a population of 5,630. Wayne 68787 is less family-centric than the surrounding county with 26.78% of the households containing married families with children. The county average for households married with children is 28.82%.
The median household income in Wayne, Nebraska 68787 is $40,029. The median household income for the surrounding county is $46,612 compared to the national median of $53,046. The median age of people living in Wayne 68787 is 23.5 years.
Wayne Weather
The average high temperature in July is 84 degrees, with an average low temperature in January of 10.7 degrees. The average rainfall is approximately 26.4 inches per year, with 32.2 inches of snow per year.
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Tropical Fish Keeping - Aquarium fish care and resources (http://www.tropicalfishkeeping.com/forum.php)
- Freshwater Journals (http://www.tropicalfishkeeping.com/freshwater-journals/)
- - 40g Blue Diamond + SS CRS (http://www.tropicalfishkeeping.com/freshwater-journals/40g-blue-diamond-ss-crs-140314/)
40g Blue Diamond + SS CRS
Hey Guys!!Tank
I left the shrimp world in November last year due to moving and only being allowed 1 tank :( So I kept my high tech for a while, but the shrimp bug kept pulling on me and I decided to give in lol
I just converted back to low tech and threw together a simple home for the shrimp. Nothing super fancy, but it should grow in and look interesting with lots of Neos crawling around.
40g Breeder
Aquariumplants.com substrate
Osmocote + Root Tabs
2x24w 10k T5 HO Odyysea
SunSun 303A Canister Filter
Hydor Inline Heater
UV Sterilizer Inline
-Pellia or Subwassertang (honestly dont know)
-Anubias nana
-Rotala rutondifolia
-Hygrophila angustofolia
-Hygrophila diformis
-Marsilea minuta
-Ludwigia repens X arcuata
-Brazilian pennywort
-Bacopa caroliana
-Crypt wendtii (green gecko)
-Echinodorus tenellus
-Clown Pleco (currently in the process of finding a new home for this guy)
-3x Otocinclus (staying)
-1x Amano (staying, but I want a few more)
-Soon to be Blue Velvet Neocaridina when I can order them :D
Water Parameters
-75 degrees
-pure SoCal tap water (super hard and pH around 7.9)
Pics (3/29/13) (PS - I turned my drop checker into a gush pod lol)
Also, This was my last thriving PFR/RCS tank from last year. It was Taiwan moss heaven in there lol
Great looking tank.
Tank Update -
Blue Velvets have been ordered, should be here this week :D
How were the blue velvets? The ones I've seen were quite disappointing... they were pretty much clear, with like the slightest slightest tinge of blue. nothing like what the photos show.... There are some blue neos now on the market that seems to be more worthy of the blue velvet name.
Absolutely beautiful tank! I'm jealous about your blues - I hope they're as pretty as their pictures! Please keep us updated on how this lovely environment grows :)
-I had a rough start with the tank due to converting to low tech from high tech. Algae took a hold while the plants adjusted and I had to fine tune the amount of light I needed for them. BUT everything has balanced out now :D
-Growth is slow but steady (Zero fertz or CO2, just Osmocote root capsules)
-Just setup a Marina Breeder Box to do some selective breeding of my Neos. Going to get a light, substrate, and plants in there shortly.
-10x Blue Diamond Neos (2 berried females as of last week, waiting for those beauties to drop :D)
-70+ Caridina Babaulti (I bought 2 berried ones and they dropped a HUGE amount of shrimplets that have grown at an insane rate. Already about the about size of my neos after only 2 weeks)
-1x Amano (I want to get this guy some more friends soon, he's lonely)
-3x Otocinclus (They only like to come out at night for some reason, oh well)
-20+ Assassin snails and growing (Now that they have settled to the low tech water parameters, there are snail orgies all over the tank all day long, I keep finding more and more eggs and babies)
One of my berried Blue Diamonds :D
http://i677.photobucket.com/albums/v...rt-d5kyaji.gif He's absolutely gorgeous! Fantastic shot, too! Loved the vids. . . your thread makes me happy :) Keep posting!
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Greens and Broccoli Salad with Peppy Vinaigrette
|Sun dried tomato halves
|4 (Not Packed In Oil)
|Torn washed leaf lettuce
|3 Cup (48 tbs) (Red-Tipped Or Plain)
|Broccoli florets
|1 1⁄2 Cup (24 tbs)
|Sliced mushrooms
|1 Cup (16 tbs)
|Sliced radishes
|1⁄3 Cup (5.33 tbs)
|2 Tablespoon
|Balsamic vinegar
|1 Tablespoon
|Vegetable oil
|1 Teaspoon
|Chicken bouillon granules
|1⁄4 Teaspoon
|Dried chervil
|1⁄4 Teaspoon
|Dry mustard
|1⁄4 Teaspoon
|Ground red pepper
|1⁄8 Teaspoon
1. Pour enough boiling water over tomatoes in small bowl to cover. Let stand 5 minutes; drain. Chop tomatoes. Combine tomatoes, lettuce, broccoli, mushrooms and radishes in large salad bowl.
2. Combine 2 tablespoons water, vinegar, oil, bouillon granules, chervil, mustard and ground red pepper in jar with tight-fitting lid. Cover; shake well. Add to salad; toss to combine.
Recipe Summary
Rate It
Nutrition Rank
Nutrition Facts
Serving size: Complete recipe
Calories 275 Calories from Fat 66
% Daily Value*
Total Fat 8 g11.7%
Saturated Fat 0.99 g5%
Trans Fat 0 g
Cholesterol 0 mg
Sodium 457.5 mg19.1%
Total Carbohydrates 44 g14.5%
Dietary Fiber 10.7 g42.9%
Sugars 11.3 g
Protein 19 g38.9%
Vitamin A 1230.3% Vitamin C 630.8%
Calcium 41.7% Iron 54.7%
*Based on a 2000 Calorie diet


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Authentic assessment refers to the practice of assessing student mastery via the completion of real world tasks in which the student applies knowledge and skill acquired in the instructional process. Authentic assessments may include writing assignments, completing individual or cooperative projects, portfolios, teacher observations, performance or demonstration assessments, or any other assigned task that will provide evidence of competency. It is a good idea to provide a selection of assessment types that will match a variety of learning styles.
Demonstration or Performance Assessments
Authentic assessment may take the form of demonstration or performance. This means that a student has the opportunity to demonstrate, through practical means, that a standard has been mastered. For instance, a student might provide evidence of mastery of a theater standard focused on blocking, upstage, downstage, center stage, monologue and projection, through design and performance, rather than via a paper and pencil vocabulary test. Such assessments can be used in other classes and tailored to different subject matter.
Portfolio Assessments
Portfolio assessments are often used when units are large or cover a number of standards. Assessment pieces contained in the portfolio provide evidence of mastery of individual standards or may provide evidence of increasing depth of comprehension of materials. For instance, a science portfolio may contain written vocabulary words associated with mollusks, drawings that outline structure and function and a three-dimensional model created by the student. This type of portfolio's value is that it allows students to demonstrate mastery by a variety of means -- collecting written information, drawing and through creative manipulation.
Oral Assessments
Oral assessments are popular with students who do not possess high level writing skills. Oral assessments can take the form of story telling or focus on documentation of question-and-answer periods in class. A teacher may use a student's oral responses to determine whether the content has been mastered. Student mastery can be assessed as part of a group exercise or individually, in a private testing session. This type of assessment can be used informally with or without student knowledge, thus eliminating testing anxiety.
Project Assessments
Project assessments provide the opportunity to demonstrate competency through completion of a project. Project assessments can be performed individually or collaboratively. Students may work together to complete a project in math that indicates proficiency in probability concepts. For example, student may use a set of dice and record the results of rolls to learn about probability. A deck of cards might also be used to learn about probability.
Photo Credits
- Brand X Pictures/Brand X Pictures/Getty Images


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- Aluminum & Copper
EVGA 100-FS-C901-KR 92mm 03/11/2014
This review is from: EVGA 100-FS-C901-KR 92mm Sleeve mITX ACX CPU Cooler, Direct Touch 4 Heat Pipe
An all black heatsink with an all black fan with different speeds. Fits just right in ATX towers. Not too big but not whimpy either. Has enough cooling power and very good airflow. I faced mine so it would blow through the heatsink and right into the PC Fan and out the back of the case with the top fans blowing in fresh air into it.
The metal clips that hold the fan onto the heatsink can be annoying if not snug. It will make a loud vibrating noise at times when the fan is going at it. Wish there was some kind of cap or grommet on the ends where it goes into the fan screw holes to keep it tight. Looks cool but poor design on that part.
1 people found this review helpful. Did you? Yes / No Thanks for the valuable feedback you provided!


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More Videos...
Caliber srt4 with 2step rev limiter
Caliber srt-4 with ND performance TCS launch control/2step/WOT box.
08 Caliber srt-4 with ND performance's Driver Mod TCS module. Consists of Launch control, Wide open throttle shifting mode and 2 step rev limiter. Great mod for the money
Lil Viper becomes worlds 2nd quickest Caliber SRT4
Lil Vipers first time out and he becomes the worlds 2nd quickest Caliber SRT4. Expect this car to run 10s next time out. 11.40@126
12 Second Caliber SRT4
Here is a very fast Caliber SRT4, that's all that needs to be said.


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Take a look at major league players. There aren't many who didn't have a breakout season by Stubbs' age. Torii Hunter is a notable exception. He was a fairly bad hitter in the minors until he was 24. Generally speaking, if you want a guy to be an .800+ OPS player with any regularity in the majors (and that is absolutely what you need from a CF), then you generally are looking out for players who've hit for .900+ OPSes somewhere on their rise up the ladder.
Yet there's likely going to come a time when Stubbs can't carry those meager stats up to the next level and then his value becomes minimal. Chances are he's either going to make a big jump in his plate skills at some point or fade away. You really don't see players that are able to maintain their game at just good enough.


text: OverviewBack to top Irwin Naturals - Aller-Pure Non-Drowsy For Eyes, Nose, & Throat - 60 Softgels Item# :82806UPC# :710363572822 Brand:Irwin Naturals Size/Form:60 Softgels Ship Weight:0.60 Servings:20 Dosage:3 Softgel(s) Irwin Naturals - Aller-Pure Non-Drowsy For Eyes, Nose, & Throat - 60 SoftgelsA healthy respiratory system depends on proper nasal and sinus function. But seasonal changes and allergens, as well as environmental irritants, can leave you feeling miserable. Irwin Naturals Aller-Pure Non-Drowsy For Eyes, Nose, & Throat provides a proprietary blend of gentle, soothing herbs, vitamins, minerals and other natural ingredients to support the health and function of your upper respiratory system. Their unique, triple pronged formula works with your body's own natural immune response, as part of a total-body approach to wellness. Upper Respiratory Support: Vitamin C and Manganese nouris delicate respiratory tissues and support healthy mucous membranes, along with standardized extracts of Lemon Balm and Holy Basil, traditionally used to support the upper respiratory tract. Supports Stable Immune Response: Significant levels of Quercetin and Rosmarinic Acid (from Perilla frutescens) support your immune system's Mast Cells in responding naturally to irritants. Potent Antioxidant and Enzyme Blend: Citrus Bioflavonoids help fight free radicals and maintain healthy respiratory function, while Bromelain helps to support sinus health. Get Serious About PotencyIrwin Naturals is so serious about potency, bioavailability and absorption that they simply call it their Mission. So Irwin Naturals invests heavily in research and cutting edge formulas. In fact, Irwin Naturals' Liquid Soft-Gel technology, along with their bioperine-infused blends and their potent herbal extracts are setting a new "Gold Standard" in the industry. Are you ready to get serious? About Irwin NaturalsFor the past 15 years Irwin Naturals has been leading the formulation of nutritional supplements in both the domestic and international market place, offering over one hundred unique products worldwide. With distribution in over 50 countries, their products rank amongst the elite. A full line supplier of natural dietary and herbal supplements, they also thrive in the high volume, high impulse product arenas, including weight loss, targeted nutritional supplements, sexual health and cleansing. Their success is driven by highly impactful packaging, best-in-class formulas and the #1 consumer-preferred delivery form – Fast-Acting Liquid Soft-Gels.


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Metroid Other M and S&P 2 Delayed
NeoGaf froum member, Nintendo Delay-Age writes:
(Metroid Other M and S&P 2 Delayed)
Just got an official email from work about two of Nintendo's biggest profile games of the year, Metroid: Other M and Sin & Punishment 2 being delayed.
Metroid: Other M has changed from being released on 6/27 to TBD.
Sin and Punishment 2 has changed from being released on 6/6 to 6/27.
April 22, 2010 at 3:49 pm
probably the best decision
of course there was no real way to guess at this, but this only means the game is going to be better
the way I see this at least
April 22, 2010 at 3:55 pm
While I would really like to see both games sooner than later, I do like that they had enough nerve to push them back if they didn't think they would be perfect (instead of quickly pushing them out the door). I think spreading them out after Galaxy 2 is also a good idea.


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Chinese Medicine Acupuncture BSc Honours
Our 2016 undergraduate courses feature some exciting new changes based on student feedback, which include providing more opportunities for you to broaden your knowledge and skills while here. See full details about the changes to our undergraduate courses.
Important tuition fee information – please read.
Alternative attendance modes for this course
Courses start in September, unless otherwise stated
View course-specific entry requirements
|Qualification type
|A Levels
|BBB in any three subjects, or BBC to include one science from Biology, Chemistry, Physics, Maths, Psychology and Geography
|International Baccalaureate
|26 points to include a minimum of 4 in two Higher Level science subjects
|Edexcel BTEC Level 3 Extended Diploma/Diploma
|DMM/D*D* in Science
|Access to HE Diploma
|Pass with 45 credits at Level 3 with a minimum of 27 Level 3 credits at Merit or Distinction with at least a Merit in all Biology or Chemistry modules plus Maths and English GCSEs at at least grade C
Any prior degree would satisfy our entry requirements.
If you are over 21 and without any formal qualifications, successful completion of the University's Foundation Year for Life Sciences Undergraduate Programmes will meet the entry requirements.
We welcome mature applicants with work experience, training or study that can be matched against specific entry requirements and where initial education has not been in English, IELTS of 6.0 in each element (or equivalent) is required and must meet 'Fitness to Study Clinical Practice'.
The medical principles originating in China between the 3rd Century BCE and 2nd Century CE remain integral components of the healthcare systems of China, Japan, the Koreas and Vietnam, and are practised today on a global scale. These principles and their development over the last 2,000 years, together with a wealth of practice and research that is currently taking place worldwide, provide the basis of this professional entry course in Chinese Medicine: Acupuncture.
Our focus is the education of competent, caring practitioners of Chinese Medicine: Acupuncture, who have the critical thinking skills combined with mindfulness, and can participate in the current debates on science and practice. You will develop your clinical skills and competence as a scholar practitioner through an NHS placement and extensive practice in our busy Polyclinic where, under the guidance of experienced tutors, your learning from the various aspects of the course is integrated.
Course content
The course is structured to support your intellectual, professional and practical skills development. Much of this is achieved through the use of themes that run through the modules and across levels. So in addition to the specific knowledge and skills required in Chinese Medicine: Acupuncture the course integrates clinical skills development, health sciences, personal and professional development, and research skills.
The course learning environment is practice led, and contact time is used to develop practice skills and to make sense of theory through its application in clinical practice and its emergence from practice.
The emphasis in the classroom is to apply materials that you will have been introduced to through recommended reading presented online.
The course offers a variety of assessments appropriate to the material assessed and to the situation in which the knowledge, skills and attitudes are eventually to be used.
Subjects of study
The following subjects are indicative of what you will study on this course. For more details on course structure and modules, and how you will be taught and assessed, see the full course document.
Year 0 (Credit Level 3)
The Foundation year is available for applicants who do not meet the entry requirements for the courses offered in complementary medicines. It is a well-established route of access into higher education for mature students (those aged over 21) without formal qualifications, and is also suitable if you have completed A Levels in non-science subjects.Subjects of study include:
- Chemistry for Life Sciences
- Introduction to Physiology and Anatomy
- Maths and Physics for Life Sciences
- Perspectives in Healthcare
- Processes in Biology
- Study Skills for Life Sciences
Year 1 (Credit Level 4)
Subjects of study include:
- Anatomy and Clinical Skills
- Chinese Medicine: Channels, Points & Palpation
- Chinese Medicine: Concepts and Context
- Chinese Medicine: Theory to Practice
- Clinical Practice 1
- Physiology
Year 2 (Credit Level 5)
Subjects of study include:
- Chinese Medicine: Pain and its Management
- Chinese Medicine: Principles, Strategies & Treatment
- Clinical Practice 2
- Pathology and Clinical Medicine
- Pathophysiology
- Research in Clinical Practice
Year 3 (Credit Level 6)
Subjects of study include:
- Acupuncture: Learning Through Cases 1
- Chinese Medicine: Learning through Cases 2
- Chinese Medicine: Learning through Cases 3
- Clinical Practice 3
- Dissertation
- Starting Your Practice
The course content is listed by year, corresponding to the full-time mode of study. If you study part-time you will study the same content, spread over four to six years.
Professional recognition
The course is accredited by the British Acupuncture Accreditation Board (BAAB), and membership of the British Acupuncture Council (BAcC) can usually be recommended on successful completion of the course.
Course team
- Felicity Moir, Course Leader
Additional costs information
To check what your tuition fees cover and what you may need to pay for separately, see our What tuition fees cover page.
Science Course for Graduates (blended learning)
Graduates applying for the BSc (Hons) Chinese Medicine: Acupuncture do not need to have science A levels. It is assumed that you will have the aptitude and skills to be able to pass the health sciences modules on the course. However, if you do think that some preliminary study would be useful we recommend the Physiology module from our Science course for Graduates by blended learning. Please visit our course pages for more information.
Applicants with relevant work or learning experiences may be eligible for Accreditation of Prior Experiential Learning (APEL) for some modules of the programme.
University of Westminster Acupuncture Graduates at St Joseph's Hospice
"This treatment has helped me with my eating and keeps my anger levels down and helps me with some symptoms from the chemotherapy. Also the advice they gave me helps me a lot."
Find out more information about the Westminster acupuncture graduates at St Joseph's Hospice in Hackney.
"I wanted to let you know that I'm really loving being a practising Acupuncturist, and to say thank-you again for your help throughout the course. I am a full time mum, and fit my clinic in around family life. I am having to turn away 1 or 2 patients a week because I can't fit them all in. As my children get older I'll gradually increase my clinic.
Have had some brilliant results (this stuff works!!!) , and most people are seeming to benefit. (Would really love to be back in the Polyclinic again -have SO many questions)!
Hope your all well, and thank-you all so very much - you really have made a HUGE difference to my life."
Fiona (graduate 2011)
The MSc course here at Westminster is great. Students have the option of completing the course on a full or part-time basis. The course provides rigorous training and incorporates in-depth academic research such as in the Post-graduate research methods module, and includes classroom based and clinical learning. Herbs, formulas, classical diagnostics and modern research are all taught and debated in depth.
I thoroughly enjoy studying at Westminster University and find it a professional and vibrant place to study."
Santosh (graduate 2011)
"After graduation I spent 6 months working in India and Nepal as a volunteer acupuncturist. It was a really amazing experience. Throughout my training at Westminster and afterwards I knew I wanted to try to work in social acupuncture. I was interested in treating a high volume of patients in a front line way, and volunteering offers the opportunity to do this. During my time in Asia I treated many patients each day in some extremely challenging environments. I had to adapt very fast, learn very fast, diagnose efficiently and accurately, treat effectively and connect with patients in a totally different way, Westminster gave me the tools to do this."
Alice (graduate 2010)
"My degree from Westminster enabled me to work within a surgery where the Primary Care Trust paid for acupuncture services where a consortium of GP's referred patients with long term conditions. This work continues to grow and I have developed my interest in the treatment of neurological disorders with acupuncture and continue to develop my professional networking with neurologists, where I promote acupuncture for conditions such as MS, Bell's Palsy, Stroke, Migraine, Spinal injuries."
Michelle (graduate 2010)
"After graduation, I worked in a new multi-disciplinary clinic. The focus was on getting NHS contracts to try to make complementary therapies available to patients with chronic health complaints. Two years later, we got our first contract which was with Durham University Hospital and once one was secure, many others followed. It gave me the opportunity to work closely with the other disciplines and understand the processes of building such a clinic. I recently applied for a scholarship in Harbin and am off the China next March for six months....very very excited!! The course at Westminster it has set me up completely for any possibility or direction of Acupuncture I could possibly wish to pursue. I know the students who graduate from Westminster with their degree have the tools to do great things for Chinese Medicine at this current time."
Rebecca (graduate 2009)
"I thought I'd let you know that I passed my Canadian license exam and have been working as an Acupuncturist for the last 6 months. The exam is very hard so warn anyone coming out to North America, revise revise revise!I'm working at www.hemma.ca. It's a Community Acupuncture clinic and yoga studio, run by a husband and wife team. It's 2 mins from home and I love it! I saw 13 patients on my shift yesterday, I see about 40-50 per week, 4 shifts a week about 4-5 hours per shift. I'm not making a fortune, but it's a living wage and best of all I'm seeing lots of patients with room to expand too. The range of people is great, everyone from budding yogis to 86 year old lady's. Cooks, gardeners and other physical jobs also seem to flock to us with their aches and pains. I've learnt a way of treating using distal points that really works, and love the vibe of treating lots of people at once, the 'hum' of Qi in the room is amazing. Thanks again for everything."
Steve (graduate 2008)
May (graduate 2008)
Our dedicated Career Development Centre is actively working with an ever-expanding network of over 3,000 employers to provide you with exceptional employability support and guidance. As a result we were nominated as finalists for a significant industry award – the NUE Awards Most Improved Commitment to Employability 2016.
We provide our students with work placements and international opportunities to support them in becoming highly employable, globally engaged graduates, and with one million businesses operating within 20 miles of the University of Westminster, over 84% of our students are in work or further study six months after graduation. Our graduates work in a variety of sectors and organisations, from small/medium-sized companies and start-ups to large not-for-profit organisations and corporates.
During your time at Westminster you will be able to use our comprehensive online vacancy service and meet with our experienced careers consultants, providing you with thorough training and support on CV writing, application forms, interview preparation and assessment centres.
In addition to this, you will receive careers support from academic staff and faculty work placement teams, offering targeted course-specific careers advice and assistance in securing a work placement during your time at Westminster. You can find out more about course-specific career opportunities by visiting the Prospects website.
For more details, visit the employability section on our site.
Career Development Centre
Our Career Development Centre can help and support you throughout your study and after graduation.
We can help you to:
- find part-time/vacation, placement and graduate jobs, including voluntary experience
- explore how to develop the skills that employers are looking for
- plan your career development
- identify your career options
- market yourself effectively in CVs, application forms and at interviews
- develop your enterprise skills
We also organise a range of presentations and networking events with employers, professional bodies, alumni and other organisations throughout the year to help you with career planning.
Find out more about the Career Development Centre.
Work Placements
Our Work Placement Teams are based in your Faculty Registry Office and can help you find a suitable placement, as well as support you in making applications, writing CVs and improving your interview technique.
More details on work placements can be found on our Work placements page.
Career options in your subject area
Our team of careers consultants work closely with Faculty departments to deliver tailored employability support, including subject-specific workshops, employer events and careers information, advice and guidance.
You can also browse the career options available to you after you graduate on the Career Development Centre's Finding work in your subject area pages and on the Prospects website.
Westminster Polyclinic
Pearl, one of our oldest patients (92 years young)
She had her first acupuncture treatment over 50 years ago. She has been having treatment in our Westminster Polyclinic since it opened.
"As far as I am concerned acupuncture is the top treatment".
"When I come in to the clinic I may not be feeling very well, and finding it hard to walk, but when I leave I feel on top of the world and I bounce out!"
Westminster has an extremely busy student clinic, where students carry out clinical work right from their first year of study. The clinic sees a variety of patients, including NHS and social services referrals. Students are closely supervised, but are expected to work to a high standard in the clinic. Students also work in an external NHS clinic in London. For more information visit: http://www.westminster.ac.uk/about-us/faculties/science-and-technology/polyclinic
Staying Relevant
Steve on part-time mode (graduate 2012, first class honours)
"Over the years I have seen the course leaders continually finding ways of improving and making the course more relevant and instructive."
The Library
The students say: "The library facilities are fantastic – bright, modern and with a huge range of books. There are a large number of computers and study spaces and there are also study rooms that can be booked so you can do group work and group study sessions."
"The library staff are really helpful, either finding information or showing you how to search and research."
EASTmedicine Summer School
Our EASTmedicine summer school, every year, offers two weeks of research-based and clinically oriented seminars and practical workshops by leading academics and experienced clinicians in the field of Chinese and East Asian medicines. (below is the link to this year's summer school event). Professor Volker Scheid gained a Wellcome Trust grant that aims to analyse the history of East Asian medicines throughout the last millenium by understanding the different modes of knowing and styles of practice that informed them. This project is aimed at creating a framework for researching East Asian medicines from a transnational perspective. For more information visit: http://www.westminster.ac.uk/eastmedicine/events/eastmedicine-summer-school
Study in the city
If you study at the University of Westminster, everything that London has to offer is on your doorstep.
Our central London campuses are ideally located for the city's fantastic learning institutions including libraries, archives and museums, as well as opportunities for shopping, eating out, enjoying London's nightlife or just simply relaxing.
After choosing your course, one of your biggest decisions will be where to live, and we aim to make that choice as easy as possible. Whether you want to apply for our Halls of Residence or live in private housing, we can help you to find the right accommodation.
Fees, funding, bursaries and scholarships
In recent years the University of Westminster's scholarship scheme has been the largest university scholarships scheme in the UK, and our Scholarships Department won the Times Higher Education inaugural Award for Outstanding Support for Overseas Students.
Personal tutoring
All students on courses of a year or more and who are registered for more than three modules will be allocated a personal tutor.
Your personal tutor will be there to support you from induction onwards, helping you to integrate into the University, academically and socially, at an early stage. They will be able to give you advice and support on academic and personal matters affecting your study, as well as developmental advice through regular individual and group tutorials.
Language support
Polylang is a University-wide programme through which you can study a language as a free choice module.
Personal advice and counselling
While most students overcome any problems with help from friends, family or a personal tutor, the University's free counselling and advice services are there if you need them.
International Westminster
With one of the UK's largest international student populations, the University of Westminster has plenty of experience in giving you the help and support you need to make the most of your time with us.
Study Abroad and Summer School programmes
Westminster's Study Abroad programme has been running for more than 15 years, and is one of the largest in the UK – each year we welcome hundreds of visiting students from universities all over the world.
If you are already studying outside the UK, the programme offers you the opportunity to study with us for one or two semesters, or for a period in the summer.
Sport and recreation
The University has extensive sport and recreation facilities, with a sports hall and gym at Harrow, a state-of-the-art gym at Regent Campus, and the University sports ground by the River Thames at Chiswick.
Students' Union
University of Westminster Students' Union (UWSU) aims to make sure you have the best university experience possible by providing a range of activities and support, from sports clubs to society groups, educational advice and social events.
"Alex and I just completed a 3-week stint in Hangzhou, China. The learning experience there was great! We impressed a couple doctors there with our knowledge in Chinese medicine theory. Some of them even let us needle their patients free-hand. That was a daunting experience as we were hesitant to touch the shaft of the needles. Even the depth at which they would insert needles was completely shocking to us, with one doctor saying that he always needles to the bone. We learned different needling techniques like the dragon's tail, chicken feet, the turtle, the tiger shaking his collar off and more! We got to see the fire needle technique for a cold bi, and a sunken acupuncture technique which was really cool. Many of the doctors here would use the holy turtle abdominal needling technique - but that being said - most of the treatments we saw were on the back. All patients here received cupping on their backs at the end of the treatment which we found intriguing. We just wanted to thank you for teaching us over the last three years. We were able to hold our space as acupuncturists there because of what you've all taught us!"
Alex and Yasinee (graduates 2015)
Between me and you...having been in contact with other practitioners that trained in the UK made me realize that my chinese medicine education is pretty sound... :-)"
Giusi (graduate 2009
Upcoming undergraduate open days
|18 March 2017
|Undergraduate open day
|Cavendish, Regent Street, Little Titchfield Street, Marylebone
|21 June 2017
|Undergraduate open day
|Cavendish, Regent Street, Little Titchfield Street, Harrow, Marylebone
Complementary Medicine - why Westminster?
Find out about student successes, career possibilities, our teaching excellence and more…
Science and Technology
Our active research and postgraduate programmes also ensure that undergraduate students are in close contact with the cutting edge of applied scientific knowledge.
Find out more about our faculty


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SAN DIEGO -- Pitching at home sure has its benefits for Jake Peavy.
The San Diego Padres' ace made quick work of the Atlanta Braves on Friday night, then hustled out as quickly as possible to catch a Toby Keith concert.
"I should have been a cowboy," quipped Peavy, a good ol' boy from Alabama. "If I get there in time, I get to see Toby sing a little bit."
Backed by a triple and double by hot-hitting Scott Hairston, Peavy led the Padres to a 4-0 win over the Braves. The reigning NL Cy Young Award winner held Atlanta to four hits and struck out seven in seven innings. He won his second straight start and for the third time in six starts since coming off a monthlong stay on the disabled list due to a swollen right elbow.
Peavy (7-5) lowered his home ERA to 1.45, the lowest in the NL and second-lowest in the majors. It was the fourth time this year he didn't allow an earned run in a home start.
"You know what? It was a good night," Peavy said.
The right-hander then praised rookie catcher Luke Carlin.
"The amount of work that he puts into it and the amount of pride he takes catching me every fifth day, I'm going to give him some props because he has sure done a nice job," Peavy said.
Manager Bud Black was impressed with Peavy.
"When he's pitching here, there's just a little different feeling," said Black, who was impressed with the life on Peavy's fastball and the curveballs he threw, including a few to Chipper Jones. "I think that you find he sets the tone on his day. You know from the time he goes out there that he's pitching with a lot of emotion. I think our guys feed off that."
Hairston agreed.
"Obviously he comes out and does his thing," Hairston said. "He's been pitching great lately. He adds fire to the game. I would say guys get motivated from that. It's encouraging to see a guy just lay it out there. I think all our pitchers do that. But there's just something about Jake.
"I'm just glad we were able to get him the run support tonight."
Atlanta's best scoring chance was in the fifth, when it had runners on second and third with one out. But Brent Lillibridge grounded out and pinch-hitter Greg Norton flied out to end the threat.
"Peavy's tough," Atlanta manager Bobby Cox said. "You're not going to get a lot of runs off him, especially in this ballpark."
Said Jones: "He threw me one pitch over the middle of the plate and I fouled it off. Otherwise, everything I saw was on the black. I can't complain about the calls."
Hairston is 17-for-34 (.500) with six doubles, five homers, nine RBI and nine runs scored in his last 11 games since June 25, hitting safely in nine of the 11 games.
Trevor Hoffman came on with runners on first and second and two outs in the ninth and struck out Lillibridge to earn his 17th save in 20 chances. He extended his big league career record to 541.
Hairston tripled into the gap in right-center off Jo-Jo Reyes leading off the first and scored on Edgar Gonzalez's groundout. He doubled with one out in the third and advanced courtesy of the Gonzalez brothers -- taking third on Edgar's single to right and scoring on Adrian's single up the middle.
The Padres added two runs in the sixth. Pinch-hitter Jody Gerut singled in Adrian Gonzalez and Kevin Kouzmanoff came around on a two-base error by left fielder Gregor Blanco.
Reyes (3-8) lost his fourth straight decision. He lasted only four innings, allowing two runs and five hits. He made his major league debut against the Padres at Petco Park just more than a year earlier.
The Braves have scored only nine runs in Reyes' eight losses.
Atlanta's Brian McCann had three hits.
Braves SS Yunel Escobar was scratched from the starting lineup due to a strained left shoulder. ... Kouzmanoff, San Diego's 3B, managed to catch Mark Teixeira's foul ball in the second even as he tumbled over the short wall down the left-field line. ... Padres right-hander Chris Young threw his second simulated game as he continues to work his way back from getting his nose broken when he was hit in the face by an Albert Pujols line drive on May 21. He'll begin a rehab assignment Wednesday night at Class-A Lake Elsinore and is still hoping to be back by late July or early August. "Physically I felt good, stuff was all right," Young said. "Overall, I was happy with the way things went. Hopefully it will keep going that way." ... The Padres will hold a ceremony prior to Saturday night's game to honor 20 players and coaches from the 1998 team that beat the Braves to reach the World Series. Among them will be Kevin Brown, the ace of that team. Brown was savagely booed when he returned to San Diego with the rival Los Angeles Dodgers in April 1999 after leaving the Padres to become baseball's first $100 million player. Brown might get a different reception Saturday night, considering that Petco Park probably wouldn't exist if the Padres hadn't reached the '98 World Series, where they were swept by the New York Yankees.


text:
Israeli air strikes killed two Gaza terrorists on Monday, according to Gaza medical sources cited by Agence France Presse. The first strike critically wounded a four-member cell from the Azzadin Al-Kassam Brigades, the armed wing of the ruling Hamas movement, one of whom later died of his injuries. A second air strike killed a member of the Popular Resistance Committees and critically wounded another man, the same sources said.
Tags:Hamas, Gaza Region, Popular Resistance Committees, terrorists eliminated, Azzadin Al-Kassam, air strikes


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Construction CPD
Gain your CPD points with Building by completing CPD modules online. Each module below contains a full technical article followed by a link to a multiple-choice questionnaire. All are fully CPD accredited.
Continuing Professional Development
CPD 2 2017: Implementing lean construction
Lean construction can be applied at every stage of a project to cut waste and improve efficiency. This CPD, sponsored by Newforma, discusses the challenges of implementing this approach and how they can be overcome
CPD 1 2017: Living walls
A living wall incorporates vegetation into facades or other internal or external walls. This CPD, sponsored by ANS Global, will examine the benefits and the key design considerations
CPD 23 2016: BIM levels of detail
Levels of detail define the content of a BIM project at different stages. This CPD, sponsored by Vectorworks, outlines the main points to consider
CPD 22 2016: Specifying steel lintels
Correct specification and installation is critical to the performance of a steel lintel. This CPD, sponsored by Catnic, outlines the main points to consider
CPD 21 2016: Specifying insulation for inverted flat roofs
This module examines the benefits of using high-performance extruded polystyrene to insulate inverted roofs, a technique that is particularly appropriate for green roofs. It is sponsored by Dow Building Solutions
CPD 18 2016: Introduction to acetylated wood
The acetylation process modifies softwood to make it more durable and dimensionally stable. This CPD, sponsored by Accsys, outlines the product's main benefits and applications
CPD 20 2016: Security entrance lanes
Automatic access systems are essential to ensure the smooth flow of pedestrian traffic to restricted areas. This CPD, sponsored by Boon Edam, examines their main components and outlines the installation process
CPD 19 2016: Air and vapour-tight OSB For timber-frame buildings
Reducing air permeability is a key principle of the Passivhaus standard. This CPD, sponsored by SMARTPLY, shows how advanced OSB panels can help to achieve this goal
CPD 17 2016: Rooflights and Part K
Part K provides essential guidance for specifiers of access rooflights, ensuring that roofs and terraces are safe to use and maintain. This CPD, sponsored by Glazing Vision, sets out the key requirements to bear in mind
Previous Modules
CPD 16 2016: Insulating flat roofs
CPD 14 2016: Hybrid systems for domestic heating
CPD 12 2016: Sustainable aluminium window systems
CPD 10 2016: ISO 9001 compliance and BIM
CPD 8 2016: Specifying suspended ceilings for health and wellbeing
CPD 6 2016: Fire safety of external cladding for high-rise buildings


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All hotels in Tulsa, Oklahoma, United States of America
1 room, 2 adults
12416 E 51st St, Tulsa, OK, 74146, United States of America
Super 8 Tulsa OK, Tulsa
No-frills Tulsa motel with indoor pool
- Free continental breakfast, free WiFi and free parking
Main amenities
- 59 guestrooms
- Indoor pool
- Fitness centre
- Business centre
- Air conditioning
- Daily housekeeping
- Self-serve laundry
- Free newspapers in the lobby
For families
- Cribs/infant beds available
- Rollaway/extra beds available
- Microwave
- Refrigerator
- Private bathroom
- Premium TV channels
What's around
- In South Tulsa
- Oklahoma Wesleyan University (1.7 mi / 2.7 km)
- Battle Creek Golf Club (2.3 mi / 3.7 km)
- All Star Sports Complex (2.3 mi / 3.8 km)
- Woodward Park (8.7 mi / 13.9 km)
- Southern Hills Country Club (9 mi / 14.4 km)
See all 58 Hotels.com reviews
Great room
TripAdvisor Traveller Rating: 3
From 115 reviews
Super 8 Tulsa OK, Tulsafrom £49
- Suite, 2 Queen Beds, Smoking
- Standard Room, 1 Queen Bed, Accessible
- Upgraded, Room, 1 King Bed
- Suite, 1 King Bed, Smoking
- Suite, 1 King Bed
- Suite, 1 King Bed
- Suite, 1 King Bed, Refrigerator
- Suite, 1 King Bed
- Room, Accessible
- Upgraded, Suite, 2 Queen Beds
More great choices
At a glance
Key facts
Hotel size
- This hotel has 59 rooms
- Check-in time starts at 3 PM
- Check-out time is 11 AM
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Pets not allowed
Extra people
- Rollaway beds available, charges may apply*
- Free WiFi in public areas
- Free WiFi and wired Internet access in rooms
- Free self parking
- Free RV/bus/truck parking
Nearby Two Star Tulsa hotels
In the hotel
Food and drink
- Free continental breakfast daily
Things to do
- Indoor pool
- Fitness facilities
Working away
- Business center
- Laundry facilities
- Free newspapers in lobby
- Accessible bathroom
- In-room accessibility
- Roll-in shower
In the room
Home comforts
- Air conditioning
- Coffee/tea maker
- Iron/ironing board
Freshen up
- Private bathroom
- Shower/tub combination
- Free toiletries
- Hair dryer
Be entertained
- Premium TV channels
Stay connected
- Desk
- Free WiFi
- Free local calls
Food and drink
- Refrigerator
- Microwave
- Daily housekeeping
Top Tulsa hotels
Recently reviewed hotels in Tulsa
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Also popular with travellers from the UK
Recent reviews
Good 3.4 /5 from 58 reviews
Super 8 Tulsa OK, Tulsa
Was looking forward to the indoor pool. It was ice cold.The bathroom in my room smelled like urine. Nothing on the breakfast buffet for low carb diet. I was just disappointed all around.
Super 8 Tulsa OK, Tulsa
Super 8 Southeast Tulsa
The hotel is not very busy and almost seems like you are alone in it at times. No food or stores within walking distance but very friendly staff and good room for the value.
Super 8 Tulsa OK, Tulsa
The staff was very helpful and friendly. The manager contacted me prior to my arrival to inform me of what appeared to be an accidental double booking so I wouldnt be charged. The receptionist was great and even recommended her favorite places to eat that delivered. 5 stars for the staff. The cleaniness of the room was good, but the light switches and the phones looked dirty and the room was pretty dark even with all the lights on.
Super 8 Tulsa OK, Tulsa
Not a bad place for the money
Not a bad place for the money. The hotel did have some wear and tear in the halls, but the room was in great shape. Internet was fast and reliable. Continental breakfast had one of those waffle makers, which I love. Downsides: the toilet tank is surprisingly loud and would randomly start filling up in the middle of the night waking me up. Road access was annoying.
Super 8 Tulsa OK, Tulsa
So when I booked this hotel, it stated there was a pool and fitness. Well needless to say they were both under construction and if I would have known when I booked it on hotels.com I wouldn't have stayed there cause i went to relax and couldn't do that had to go to a fitness center and pay for there equipment. I don't think that was fair. So I think that they should have disclosed that under there hotel. For whatever length it was down. Ok and not having breakfast ready at it's scheduled time either was kinda of a pain when you need to leave by a certain time, or you have to let them know that they are out of a product during breakfast time. Also please respect your clients and don't watch preaching shows when for yourself when are asked to watch the local news and weather so us as clients know whats going on in a city we've never been.
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