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Deconstructed Sushi Roll (Paleo/AIP)
I love sushi rolls, but they've been off my table for a while since I'm not currently eating rice. My deconstructed sushi roll incorporates all the flavors you get from the real thing with seaweed cauliflower "rice" making a tasty base for this recipe. As my husband and I regularly eat salmon, I'm always looking for different ways to flavor it for variety. I had the idea to marinate it in coconut aminos (a soy-free version of soy sauce) and wasabi powder and pair it with seaweed cauliflower "rice." To round it out, I topped this dish…read more


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Both the city and the American Civil Liberties Union of Colorado are claiming victory in the first battle of a new lawsuit.
Filed Nov. 28 by the ACLU on behalf of a diverse list of clients that includes, among others, a panhandler, the Pikes Peak Justice and Peace Commission, and the Denver Voice newspaper, the suit centers on Colorado Springs' new downtown no-solicitation ordinance. Approved by City Council on Nov. 27 on an 8-1 vote, it will ban all solicitation from public areas in the downtown core.
City and ACLU attorneys met Nov. 30 for their first hearing in the lawsuit. The ACLU had asked Denver federal judge Marcia Krieger for a preliminary injunction and temporary restraining order to prevent the ban from going into effect as early as Dec. 2.
The judge denied that action, citing a lack of urgency — because the city told the judge that the law wouldn't go into effect until Dec. 19, and tickets wouldn't be issued for another month after that.
To ACLU legal director Mark Silverstein, the apparent change of date looks like a dodge — and a victory.
"There were four [city] lawyers researching this for a year," Silverstein tells the Independent, "and then they say, 'Oh my God, we were taken by surprise, we need some more time.'"
City Attorney Chris Melcher, however, sees things differently, stating in a press release, "We are pleased the court agreed with the City of Colorado Springs that there was no need for any emergency action at this time, and denied the ACLU's temporary restraining order."
Asked by the Indy, Melcher states in an e-mail that he had never planned on a Dec. 2 effective date: "There is no change in the effective date of the ordinance. The December 2nd date reported by some outlets was inaccurate. There is a process that must take place before a new ordinance goes into effect, including having it published. This process is being followed."
But Melcher did quote Dec. 2 as the probable effective date to Gazette reporter Daniel Chacón in City Council chambers, in a conversation overheard by the Indy.
And in a court document, ACLU staff attorney Rebecca T. Wallace notes, the mayor and City Councilors repeatedly told the public that the law actually would be in effect during the holiday shopping season.
In fact, it wasn't until an e-mail from Melcher to ACLU staff attorney Sara Rich from Melcher on Nov. 28 saying "[t]he ordinance will likely not be effective until December 5 at the earliest," that the ACLU claims there was any indication the effective date might not be Dec. 2.
"Apparently in an attempt to gain a continuance of the emergency hearing," Wallace states in the court document, "[the city] has performed an about-face by formulating a new plan to delay the effective date of the ordinance to December 19, 2012. This new plan involves, among other things: the Mayor holding up the ordinance for five days and the clerk holding up the ordinance for another week or so."
The city, however, hasn't tied its opponents' hands for long. The ACLU still plans to ask a judge to take lasting action by preventing the solicitation ban from going into effect until its lawsuit is resolved.
But with the law on hold until Dec. 19, that conversation can wait for the next hearing, scheduled Dec. 13.
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19 God, the Lord, is my strength;
ghe makes my feet like the deer's;
he makes me htread on my ihigh places.
jTo the choirmaster: with kstringed4 instruments.
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2 Sa 2:18
Am 4:13 Mic 1:3
Dt 32:13 Dt 33:29
Ps 4
Is 38:20
Hebrew my stringed


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Contact Us
Forney Industries, Inc.
2057 Vermont Drive
Fort Collins, 80525
Phone: 1-800-521-6038
Email: email@example.com
Hours: 7 – 5 p.m. MST Monday – Friday
You have a job to do and Forney is here to help you in any way we can. We are committed to your success and will do anything in our power to help assure it.
Forney Customer Service provides answers:
Product knowledge: Forney Customer Service is well versed in all our products, and we are constantly expanding our knowledge base.
Customer experience: Forney Customer Service makes every call special by tailoring it to your personal needs.
Quality commitment: Forney Customer Service is committed to excellence in every way, at every level, whether you are an end user, a dealer, or a sales rep. You are important to us.
Always answer: At Forney Customer Service we are committed, that if we can't take your call, respond to your email or answer your question right away, we WILL get back to you promptly with the information you need.
Golden rule: At Forney Customer Service we believe in treating each other, and everyone who calls with the appreciation and respect they deserve.
"We will go the extra mile to answer your questions, resolve your issues, and get the products you need into your hands."
Forney Customer Service Attitude: "A continuous commitment by all of us to provide you with an outstanding overall experience through our words and actions."


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This is my recipe for baking banana bread, I hope you try it.
5 small ripe bananas, pureed
1/2 cup unsalted butter
1 cup brown sugar
1 1/4 cup all purpose flour
1 tsp. ground cinnamon
1/8 tsp. nutmeg
4 tsp. baking powder
1/2 cup raisins
1/2 cup nuts
Preheat oven to 350° F.
Grease and flour a baking pan, set aside.
In a bowl combine the flour, cinnamon, nutmeg and baking powder, set aside.
In another bowl mix with the electric mixer the butter with the sugar, until is fluffy, add in the eggs, one by one, mixing after each one.
Combine the two mixtures, add the bananas, the raisins and nuts. Stir all the ingredients until well blended with a wooden spoon.
Pour into a baking pan.
Bake for about 55 minutes, or until you insert a knife in the center and comes out clean.


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Total Cost: $5.89
- Fabric: $4.89
- Buttons: $1
- Hook and Eye/Snaps: stash
- Interfacing: stash
- Pocket Lining: stash
During the process of adding length to the waistband I screwed up the buttonhole placement. So instead of putting buttonholes in the wrong spot and ruining my skirt, I used a hook and eye and a snap and sewed the buttons on as decoration.
|For the pocket lining I used some crepe-back satin I had left over from my Ruffle Skirt
|Sox loving my pajama skirt


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Deaths in 1437 DR
- Crown Prince Emvar Obarskyr dies in an ambush by Sembian forces south of the Vast Swamp.[1]
- Jemra Rhindaun is killed in a failed assassination attempt on Azoun V.[1]
- ↑ 1.0 1.1 Brian R. James (July 2008). "Backdrop: Cormyr". In Chris Youngs ed. Dragon #365 (Wizards of the Coast), p. 16–24.


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Posts Tagged 'Mary Ellen Gurewitz'
Landmark Court Case Win
Ruling means straight-ticket voting remains an option for Michiganders. Mary Ellen Gurewitz, a lawyer at the Detroit law firm of Sachs Waldman and Detroit Jews for Justice (DJJ) co-founder and steering committee member, recently won a historic case for voting rights in Michigan's straight-ticket voting issue. Straight-ticket voting is a tool that allows a voter…Read More


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Opening your mind may mean taking inventory on what is in there already. To make progress will mean purging all those old thoughts that have been preventing you from taking action on that idea you have been wanting to explore. Get ready! Once you open your mind it will bring a whole world of new opportunities to you!
Posted on 07/27/2013 at 12:00 AM


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We offer round the clock Emergency Service, 24 / 7.
Your phone call will be answered promptly and we will route our closest locksmith
immediately to your location.
Whether you are locked out of your home, office or auto call us anytime we'll get you back in.
In an emergency scenario firing your employe, or any other reason that require you to change your locks Call us 24 hours 7 days a week.
Rapid response, highly-qualified staff, and state-of-art tools and equipment to protect
your home, business, automobile, and family.
We provide lock-out remediation emergency break-in repairs
at all hours of the day or night.
We have Solutions for all your security needs to protect your valuables.
For your home, we can provide immediate access in the case of a lockout.
If you're burglarized, we can quickly replace locks, deadbolts, and security
hardware to restore your peace of mind.


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This delightful plant is virtually identical to Tamarix ramosissima 'Pink Cascade' except it has plumes of pale pink flowers earlier in the year, in late spring or very early summer. Ideal for growing in flowering borders, woodland areas or windy, coastal positions.
Supplied Size: 3L/4L pots (approx 3 - 4 years old, 60 - 80 cm tall)


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I Was Born!!!!I was born on May 17th, 1997. I was very small when I was born.
MovingI moved from my tralier house to the house I live in now. We moved from a much bigger town, but I don't remember it because I wasn't even two yet.
BrotherMy little brother Spencer was born. He was small, but still was bigger than I was when I was born.
New HampshireI went to visit my friend in New Hampshire. My whole family came along, and we had an awesome time!
1st Day of PreschoolI went to preschool when I was four. I went with quite a few of the people that are in my class now.
First DogWe got our first dog in 2002. She was a beagle, and we named her Daphne Angel.
KindergartenI went to kindergarten in 2003. I made quite a few new friends, and once a boy even gave me a note that said he loved me!
Disney WorldWe went to Walt Disney World in Florida. We spent Christmas there, and played in the ocean a lot!
Second DogWe got our second dog. She is a huge yellow lab that we named Macy Rae. She is huge, but very nice; she never gets angry!
Washington D.C./New York City!!!I went to Washington D.C., New York City, and the Hershey Chocolate Factory. I went with my parents, my brother, Chris Davis, Michelle Davis, Cody Davis, and Connor Davis. It was reallyyyy fun!!
CommunionI had my first communion. I had it with a few of my other classmates.
ConcertMy friend and I went to a Justin Bieber concert in Minneapolis! It was really fun!
Midnight Premiere!!!I went to the midnight premiere of Harry Potter and the Deathly Hallows part 2! I went with my family and friends that I had not seen in forever! It was really, really fun and the best movie ever!!!
Band CompetitionI went to Sioux City, Iowa for my first ever high school band competiton! It was really fun, and we made our teacher drink a mixture of some nasty food! :)
Football PlayoffsMCM plays Flandreau for football playoffs in Salem. MCM is going to kick their butts!!!


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|Annie Wiggins Guest House
|1004 Park Avenue, Galena Illinois
Phone 815-777-0336
|For reservations & availability please call: 815-281-0408
1004 Park Avenue, Galena, Illinois 61036
Copyright 1999-2013 Annie Wiggins Guest House / Bill & Wendy Heiken. All rights reserved.
Send email to: firstname.lastname@example.com
Last Revised: 6/4/2013
|Ghost Tours
Join Annie and Friends for a
walking tour of
Galena's Historic Tales
Legends and Sights!
|Review of tour by the Seniors Network
Click Here to Review Video


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Starbucks Coffee
G/F Eastwood City Walk 2, E. Rodriguez Jr. Ave. (C5), Eastwood City, Quezon City, Metro Manila
- 60 Reviews
- 110 Recommend
- 47 Reviewers
Primary Details
- Category:
- Coffee
- Business Hours
- Open: 7:00a - 1:30a
- Phone
- +6326876504
More Info
- 7:00a - 12:00a
- 7:00a - 1:30a
- 7:00a - 1:30a
- 7:00a - 1:30a
- 7:00a - 1:30a
- 7:00a - 3:30a
- 7:00a - 1:30a
Price Range
₱110 - ₱155
Most Recent Reviews
I liked it.
- No. of Comments: 0
- No. of Likes: 0 Likes
Trying out this Vanilla Sweet Cream cold brew for a boost while at work. It's my first time to try their cold brew and kinda liked it. The first sip reminds me of Chai latte but the taste of coffee was in it anyway after a few sip.
It's not that strong but it's just right for my liking. It's not that sweet either so it's a perfect balance imho.
- No. of Comments: 1
- No. of Likes: 6 Likes
I prefer going here in the morning, a usual Starbucks Cafe with very relaxing ambiance and welcoming staff.
- No. of Comments: 5
- No. of Likes: 2 Likes
Tried a different drink, I bought Matcha Coffee (Php140) and I liked it. Matcha plus coffee you can't go wrong with it.
This branch is always full and gets a bit warm when you stay outside. Unlike the other branches within the area.
- No. of Comments: 3
- No. of Likes: 6 Likes
When I first tasted you, I get addicted...
Yes, thats what I felt after drinking one of Starbucks' new concoctions: Iced Shaken Hibiscus tea with Pomegranate pearls. It was really fun drinking it. Hibiscus was definitely refreshing, sweet and fruity combined with my favorite pompom (thats what my sister and I call pomegranate). The pearls added the fun cause its like tiny bubbles with full of flavor. So dont waste the bubbles.
Highly recommended. Something to look forward . It will run for 3 months as one of the partners advised me and will officially launch tomorrow, September 14, 2016.
- No. of Comments: 0
- No. of Likes: 3 Likes
lay back sunday while zippin my favorite dark mocha frap (no whip and nonfat milk)
- No. of Comments: 2
- No. of Likes: 2 Likes
Love green tea?
Love chocolate?
Why dont combine it?
Yup! This is inspired from my fave greentea dessert of Kimono Ken . And yes chocolate - greentea combination is really a blast. You can request to just have a drizzle if you want it for free or have the mocha sauce as an add on.
- No. of Comments: 2
- No. of Likes: 1 Like
I still prefer their Oreo cheesecake!
- No. of Comments: 0
- No. of Likes: 5 Likes
My daily morning ritual..
need dose of sugar to power up
Good customer Service
The best
- No. of Comments: 0
- No. of Likes: 2 Likes
That is the white chocolate mocha in my personal tumbler sorry for the bad pic.
The baristas here are sooo nice and to think that it's usually too early in the morning to be so happy and nice  I know it's their job but I sometimes find it hard to be uppity all the time so yay for them!
- No. of Comments: 0
- No. of Likes: 1 Like
The Dark Mocha Panacotta frap was surprisingly good! I had my tumbler so it was easier to handle mixing the panacotta from the bottom. It balanced with the mocha really well, not too sweet and not too bitter. Going to try the Summer Berry one soon
- No. of Comments: 2
- No. of Likes: 7 Likes
Love their Dark Mocha Panna Cotta Frappuccino Blended Beverage!  However, it's a bit pricy at 180 php for Tall size.
- No. of Comments: 0
- No. of Likes: 1 Like
4th consecutive day having coffee at Starbucks. Haha. With a slice of a guilt free cake best paired with a warm Cafe Latte.
- No. of Comments: 4
- No. of Likes: 4 Likes
Not sure if I should be happy or not about my coffee, but still Starbucks is the best!
I ordered a tall brewed coffee on a grande cup. But it turned out I got a grabde serving! So, it's caffeine overload for me! Hahaha perfect for a sleepy afternoon!
- No. of Comments: 3
- No. of Likes: 3 Likes
Slow service it always takes me 5-10mins to order.. I dont know why may it be short or long line
- No. of Comments: 1
- No. of Likes: 1 Like
Mocha Frappe!
- No. of Comments: 0
- No. of Likes: 0 Likes
This place is just newly renovated, it looks fantastic!
I love their caramel macchiato, bread and pastries! I love everything about Starbucks! It's comfort coffee (analogous to comfort food) for me.
Their staff members/ baristas are all very friendly, accommodating and efficient.
Today I tried the Taste of Heaven Cake. It was sooo good. It deserves that name because it really did taste like heaven it was perfect! I can't believe it took me this long to try this. I was told that it isn't available all the time in all branches. It should be! It goes really well with my hot caramel macchiato.
- No. of Comments: 0
- No. of Likes: 3 Likes
The coffee jelly frappuccino never fails to perk me up on a long work day! My forever fave. :)
- No. of Comments: 0
- No. of Likes: 0 Likes
Newly renovated this 2014 plus Grande Hot Soy Toffee Nut Latte without Whip Cream is good!
- No. of Comments: 0
- No. of Likes: 1 Like
I am not really a huge fan of Starbucks because their drinks are too sweet for me, and of couse, I'm not just a coffee person. But since our Boss was going back to Australia, teamates wanted us to give her a planner!
I ordered the Double Chocolaty Chip Crème Frappuccino® Blended Crème for P180.00. I think, the sweetness level of this one is just right. But, I didn't enjoyed since they forgot to give me straw!
I just hate the surroundings of this Starbucks in Eastwood. So many smokers and you could not enjoy the place if you are dining outside. I guess Starbucks store is connotative with smoking area nowadays.
- No. of Comments: 0
- No. of Likes: 1 Like


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Grass Types
Find Lawn Service
Approach Spring Lawn Fertilizer Carefully
by Dawn West, All About Lawns Columnist
May 23, 2007
Once spring begins in earnest, one of the first lawn maintenance tasks most of us think of is applying fertilizer. What else will green your lawn up and get it going with such gusto? While an application of spring fertilizer isn't a bad idea, it's important to choose your fertilizer wisely and apply it correctly--or your heavenly spring fantasy may morph into a scorched lawn nightmare. Here are two spring fertilizer pitfalls to avoid.
How would you like to improve your lawn?
Make it greener
Eliminate patches
Less weeds
Make it thicker
Do you own your home?
Enter your zipcode:
Don't Overdo Spring Fertilizer
A spring fertilizer that's especially high in nitrogen will likely do several things. The first is accelerate your lawn's growth. Sounds great, but the downside is all the early top growth typically comes at the expense of your lawn's roots, and during wet spring weather, an over-fertilized lawn can be especially vulnerable to lawn fungus. While some fertilizer is a great start to your season's lawn maintenance, in the spring consider a fertilizer with lower nitrogen content than you'd use at other times of the year, and be sure not to over-apply it.
Watch Out For Weed and Feed Fertilizers
Spring is a fresh start, and it can seem like a great time to tackle all your lawn maintenance tasks: fill in thin areas, kill weeds, and get your lawn growing vigorously again. Unfortunately, as wonderful as doing it all at once sounds, it's rarely that easy. If you're spreading any new seed, whether you're putting in an entirely new law, or just over seeding damaged patches, do not apply a weed and feed fertilizer. The herbicide will kill young grass along with the weeds. For now, a fertilizer without any herbicide is the way to go.
Spring fertilizer done right is an important part of a lawn maintenance program. Avoid these pitfalls, and your yard will be off to a great start.
About the Author
Dawn West B.A. holds a B.A. in English from Harvard University and teaches writing at Oregon State University.
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This is a sponsored conversation written by me on behalf of Wet Ones® Hand Wipes. The opinions and texts are all mine. We are in full summer time mode here in North Carolina. What is the first thing that you remember about summer from when you were a kid? Anything messy come to mind? How about s'mores, popsicles, painting, toad trapping and overall tons of messes? These Oreo S'mores Popsicles …continue reading
Who says good-for-you treats can't also be indulgent? Yes, these are supposed to be healthy snacks for kids, but this mama might have snuck one or two herself, because it's still hot, and when you need to cool off, nobody can resist this favorite flavor combination in a frosty form like these Banana, Peanut Butter and Chocolate Chip Cheesecake Frozen Yogurt Pops. Banana, Peanut Butter and Chocolate Chip Cheesecake Frozen …continue reading
I don't know how the weather is where you are, but in NC it's HOT! I don't think it's dipped below 90 since we moved here. In order to cool off and also celebrate national cheesecake appreciation, I've whipped up these Lime Cheesecake Popsicles that are sure to cool you off and fill your need for cheesecake. Lime Cheesecake Popsicles Right before we made our move I had whipped …continue reading
I got back Monday morning from Food & Wine Conference and I learned so much while I was there. One of my favorite sessions was a food styling session done by Denise Vivaldo. She was not only hysterical, but I learned so many tips that'll save me time as well as save me from melted popsicles. These Lime Cheesecake Popsicles taste just like the real thing and they are so …continue reading
Due to the meal planning of 21 Day Fix, I have renewed my love of fresh fruits. We're even trying a new fruit a week in our house so that I'll expose my girls to more variety. No matter what though, I always think of watermelon and blueberries as my go-to summer fruits. Both of my girls love them. Since it's been close to 100 degrees since moving to North …continue reading
When I think of summer my mind automatically goes to strawberry shortcake for some reason. I think it's largely due to the fact that the grocery stores now keep all the ingredients for an easy strawberry shortcake right by the strawberries. Fortunately, it is so hot here in NC that it caused me to think outside of the box to create a refreshing dessert. These strawberry shortcake ice pops are …continue reading
I am a member of the Mom it Forward Blogger Network and I was compensated by Wet Ones for this article. We are in full Summer Fun mode, which means tons of Summer popsicles like my Banana Avocado Popsicles. I've been making an effort to attempt to keep the treats as healthy as possible. I was inspired by my Watermelon Banana Smoothie to try another recipe with fresh watermelon. These …continue reading
If there were two fruits that my girls could not live without on a daily basis it would definitely be bananas and avocados. They seriously go through them like they're chocolate , which you've seen is also prevalent in my house {Chocolate Brownies Recipes}. In order to balance the cupcakes with some healthy snacks, I created these perfectly Summer Banana & Avocado Popsicles. I've also put together some more of …continue reading
Avery is eating solid foods now, which also means that she gets to take part in all of the fun Summer treats. I'm not sure who is more excited about that Riley or my dad. Grandpa loves feeding his grandbabies sweets and he is especially known for ice cream and popsicles. In order to keep the popsicles a bit healthy, I'm giving a couple a try before true popsicles …continue reading
After a fabulous vacation in the gorgeous US Virgin Islands of St. John, I thought it would only be fair to put together some Frozen Treats for all of you. I have everything from adult beverages to perfect popsicle treats for the kiddos. So sit back and get cooled off with one of these delectable frozen treats and I'll see you all tomorrow night for another Whimsy Wednesdays. 20 Frozen ...


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Podcast: Play in new window | Download
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We talked with Jenelle Marie Pierce – the Founder & Executive Director of The STD Project, a Spokesperson for PositiveSingles.com, an STD Expert for Answers.com, an eater of jello, and a lover of snow. She is also proof an STI is not a deal-breaker or the end of your world; rather, it is merely an unexpected curve-ball in this interesting game we call life.
Have a certified Care Advisor from STD Test Express answer your questions – US only
Ways to Reach Us at The Ascension Show
Email – firstname.lastname@example.com
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text:
When you think social bookmarking, you think Digg and De.licio.us. They are the big names, and the sites that have made the biggest names within this category. Yet just like every other category, the biggest doesn't necessarily mean it's the best for your business.
If you fall in the small business category, and provide news and tips that appeal to other small businesses, give BizSugar a try. BizSugar is a small business focused social bookmarking site that provides categories in the marketing, finance, franchises, global business, legal, management, technology and startup categories. The top voted stories receive front page status, and can usually wind up on the front page with 20 to 30 votes, or sugars. Readers also have the ability to send a post to Twitter, Stumble Upon, Delicious, Facebook, Google Buzz or Blogger, or email it to a friend.
Like other social bookmarking sites, you have the ability to create a profile, including photographs, links to your website, RSS to your blog, and links to other social networking sites. Once your profile is built, you can begin sharing news, adding friends, commenting and voting on other stories, and building relationships with other BizSugar members.
The best way to see if you are a match for the BizSugar community is to head over and take a look around. Start by looking at today's top stories on the home page. You can click to top stories yesterday, over a 7 day period, 30 days, and past year. Also take a look at the hot topics to see what's trending now.
Once you have a good idea what's being submitted, and what people enjoy, start submitting.
Don't forget to download your FREE Blogging Planner today.
Blogs can benefit any website but don't worry if you can't do all the writing yourself … you can hire a ghost blogger for that!


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« be free lady bugs, be free! |
| Hello happiness, I'm so glad I found you. »
This is a commission painting I just finished.
I was instantly taken by this little Italian Greyhound, who was so loved by his family. I had to share him with you.
03:35 PM in commissions, creative thursday, illustration friday | Permalink


text:
15 July 2005
England cricketers past and present stole the show at the fifth Retail and Leisure Property Awards on 29 June.
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text:
The Wheel of Osheim is the third and last book in The Red Queen's War series by Mark Lawrence.
The Wheel of Osheim is turning faster than ever, and it will crack the world unless it's stopped. And Jalan is just the man for the job, even though he tries to convince everyone he isn't. Jalan and Snorri face danger upon danger, from the minions the Dead King, the mysterious Lady Blue, to the horrors of Hell itself. The Wheel must be stopped. Nothing else, and no one else matters. Continue reading


text:
- Home:homepage People Faculty Alphabetical Listing G
- People
| Name:GUO Mingyu
Title:Associate Professor
Tel: 86-512-65882521 (O)
Email: firstname.lastname@example.com
Group Website
B.S. Lanzhou University (1998-2002)
M.S. Lanzhou University (2002-2005)
Ph.D. Fudan University (2005-2009)
Postdoc Eindhoven University of Technology (2009-2011)
Research Interests: Supramolecular self-assembly and functional supramolecular materials, strong and elastic supramolecular hydrogels, droplet-based microfluidics and shape-memory materials.
Representative Publications
1. Mingyu Guo, Hans M. Wyss, Patricia. Y. W. Dankers, E. W. Meijer, Hydrogelator with Shape-memory properties, EP11168974, 2011.
2. Mingyu Guo and Hans M. Wyss*, Micromechanics of Soft Particles, Macromol. Mater. Eng. 2011, 296, 223–229.
3. Mingyu Guo,* Ming Jiang*, Supramolecular Hydrogels with CdS Quantum Dots Incorporated by Host–Guest Interactions, Macromol. Rapid Commun. 2010, 31, 1736–1739
4. Mingyu Guo and Ming Jiang*, Non-covalently Connected Micelles (NCCMs): the Origins and Development of a New Concept, Soft Matter 2009, 5, 495-500
5. Mingyu Guo, Ming Jiang*, Stergios Pispas, Wei Yu, and Chixing Zhou, Supramolecular Hydrogels Made of End-functionalized Low-molecular-weight PEG and α-Cyclodextrin and their Hybridization with SiO2 Nanoparticles through Host-guest Interaction, Macromolecules 2008, 41, 9744-9749
6. Mingyu Guo, Ming Jiang* and Guangzhao Zhang, Surface Modification of Polymeric Vesicles via Host-guest Inclusion Complexation, Langmuir 2008, 24, 10583-10586
7. Mingyu Guo, Ming Jiang*, Macromolecular Self-assembly Based on Inclusion Complexation of Cyclodextrins, Prog. Chem. 2007, 19, 557-566
8. Mingyu Guo, Mingzhu Liu*, Rui Liang, Aizhen Niu, Granular Urea-formaldehyde Slow-release Fertilizer with Superabsorbent and Moisture Preservation Properties, J. Appl. Polym. Sci, 2006, 99, 3230-3235
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- Research article
- Open Access
- Open Peer Review
Impact of clinical pathway on clinical outcomes in the management of COPD exacerbation
© Ban et al.; licensee BioMed Central Ltd. 2012
- Received: 22 September 2011
- Accepted: 15 June 2012
- Published: 22 June 2012
Exacerbations, a leading cause of hospitalization in patients with chronic obstructive pulmonary disease (COPD), affect the quality of life and prognosis. Treatment recommendations as provided in the evidence-based guidelines are not consistently followed, partly due to absence of simplified task-oriented approach to care. In this study, we describe the development and implementation of a clinical pathway (CP) and evaluate its effectiveness in the management of COPD exacerbation.
We developed a CP and evaluated its effectiveness in a non-randomized prospective study with historical controls on patients admitted for exacerbation of COPD to Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Consecutive patients who were admitted between June 2009 and December 2010 were prospectively recruited into the CP group. Non-CP historical controls were obtained from case records of patients admitted between January 2008 and January 2009. Clinical outcomes were evaluated by comparing the length of stay (LOS), complication rates, readmissions, and mortality rates.
Ninety-five patients were recruited in the CP group and 98 patients were included in the non-CP historical group. Both groups were comparable with no significant differences in age, sex and severity of COPD (p = 0.641). For clinical outcome measures, patients in the CP group had shorter length of stay than the non-CP group (median (IQR): 5 (4–7) days versus 7 (7–9) days, p < 0.001) and 24.1% less complications (14.7% versus 38.8%, p < 0.001). We did not find any significant differences in readmission and mortality rates.
The implementation of CP –reduced the length of stay and complication rates of patients hospitalized for acute exacerbation of COPD.
- Chronic obstructive pulmonary disease
- Clinical pathway
- Clinical outcomes
- Length of stay
Chronic obstructive pulmonary disease (COPD) is characterised by progressive, partially reversible airflow obstruction and lung hyperinflation with significant extra-pulmonary manifestations and co-morbid conditions [1]. COPD is the fifth leading cause of death worldwide and the 12th leading cause of disability [1, 2]. In Asia, WHO estimates that the number of COPD cases will exceed by three times the total number of COPD cases for the rest of the world by the year 2020 [3]. In Malaysia, COPD ranked fifth in terms of disease burden [3] and its prevalence is projected to rise. This chronic condition is progressive in nature resulting in a steady decline in lung function. Its progression is accelerated by episodic exacerbations, typically requiring inpatient hospital care at increasing frequency as the disease progresses. A COPD exacerbation is characterized by an acute worsening of the patient's baseline symptoms including dyspnoea, cough and/or sputum, which may require alteration in regular medication.
Exacerbations, a leading cause of hospitalization in patients with COPD, affect the quality of life and prognosis. All-cause mortality after hospitalization for COPD exacerbation is high up to 50% particularly in those requiring ventilator supports [4]. Patients with frequent COPD exacerbations have poorer quality of life and accelerated decline in lung functions. Suboptimal treatment of COPD exacerbations is a major concern. It increases health-care resources utilization and cost, and may sometimes cause detrimental effects to patients. Treatment recommendations as provided in the evidence-based guidelines are not consistently followed.
A large study in USA involving 70,000 patients admitted for acute COPD exacerbation found that only 30% patients received all the recommended treatment according to the established guidelines [5]. We have also previously shown that the compliance to our national guideline of COPD management was only 60% for the treatment of moderate to severe stable COPD [6]. Among the reasons for failure to adhere to the treatment recommendations include lack of awareness of the COPD guidelines particularly among the non-respiratory and primary care physicians, and absence of simplified task-oriented approach to care. Thus, there is a critical need to address this increasing gap between the guidelines and clinical practices, particularly in the hospitals of developing countries, by implementing and evaluating clinical care practices tailored to local settings. Clinical pathways can provide a link between establishing clinical guidelines and practicing them.
A clinical pathway (CP) - also known as a care pathway or multidisciplinary action plan (MAP) – is defined as an interventional plan for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period [7]. The pathway outlines the main clinical interventions that are carried out in the hospital by a group of health care professionals responsible for the care of the patient. It incorporates locally agreed clinical standard practices as well as guidelines into a systematic approach for managing a specific group of patients with the aim of improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources [7].
COPD presents a significant disease burden in Malaysia and is reflected in hospital admission rates for COPD exacerbations. The management of COPD admissions is guided by local standard practices and clinical guidelines established by the Ministry of Health of Malaysia. However there are inconsistencies between guidelines and their application in daily clinical practice. While existing clinical guidelines for COPD provide evidence-based and consensus-derived statements of optimal care for patients with COPD, such guidelines do not provide an organizational framework for managing patients within a hospital setting, resulting in inconsistent application of clinical plans and variable patient outcomes. COPD CP has been successfully implemented in developed countries [8] and previous studies suggest that its usage results in improved clinical outcomes [9, 10]. The adoption of COPD CP in Asia, however, lags behind and evidence of its effectiveness in developing countries is less clear.
To date, there has been no published study on the effectiveness or impact of COPD clinical pathway development and implementation in Malaysia and also very few studies worldwide. In view of the positive outcomes reported in the literature in decreased LOS and readmission, we decided to examine the benefits and its effectiveness.
In this study, we report the development and implementation of a COPD CP in a teaching hospital in Malaysia, and evaluate its effectiveness by comparing the length of stay (LOS), complication rates, readmissions, and mortality between CP and non-CP COPD patients.
This was a non-randomized, prospective study with historical controls in hospitalized patients with COPD in the Universiti Kebangsaan Malaysia Medical Centre (UKMMC). The study was carried out over a period of 31 months, from June 2008 to December 2010 starting from the development of COPD until patient recruitment. The CP was implemented in June 2009. All patients gave written informed consent and the study was approved by the Research and Ethics Committee of the Faculty of Medicine, Universiti Kebangsaan Malaysia (FF-154-2008).
The study population consisted of two groups which were the non-clinical pathway (non-CP group) and the clinical pathway group (CP group). The CP group was recruited prospectively from patients that were admitted with exacerbation of COPD between June 2009 and December 2010. For this study, an acute exacerbation of COPD (AECOPD) was defined as an acute worsening of dyspnoea, cough or change in quality or quantity of sputum requiring a change of regular medication. These symptoms should have been present for at least 3 days. We included adult patients aged 40 years and above with a diagnosis of exacerbation of COPD, and excluded patients with the following conditions: (i) congestive cardiac failure, (ii) long term oxygen therapy use (LTOT) ≥ 15 hours/day, (iii) underlying malignancy, (iv) active tuberculosis, (v) diffuse interstitial lung diseases, or (vi) pulmonary thromboembolic disease. Patients with LTOT were excluded as co-existing cor pulmonale would be a confounding factor that could prolong the length of hospitalization. Patients on LTOT represent a small subset of COPD patients in the advanced stages of their diseases. We chose to exclude these patients in our study.
For the non-CP group, COPD patients were recruited retrospectively from the medical records of patients admitted with a diagnosis of exacerbation of COPD between January 2008 and January 2009. Besides the clinical diagnosis by the attending physician, we required evidence of spirometry readings consistent with COPD: obstructive lung disease FEV1/FVC <70% with minimal reversibility (<12%), together with a significant smoking history of more than 10 pack-years. In our teaching hospital, the GOLD [2, 11] and Malaysian Clinical Practice Guidelines (CPG) were available as references for the management of acute COPD exacerbation [1]. We limited the retrospective review of cases to 1- year (Jan 2008 to Jan 2009) prior to commencement of the prospective recruitment of the CP group (June 2009), so as to ensure the treatment regimes and access to pulmonary rehabilitation programs were comparable.
Stage of COPD and percentage predicted FEV1
Stage of COPD
Percentage predicted FEV1
Stage 1
> Or = 80%
Stage 2
Stage 3
Stage 4
Development and implementation of the COPD clinical pathway
The paper-based pathway for COPD was developed by Universiti Kebangsaan Malaysia Medical Centre (UKMMC) in collaboration with United Nations University International Institute for Global Health (UNU-IIGH). The development was conducted in series of workshops involving the Respiratory Unit of UKMMC, UNU-IGH, and the Department of Public Health. In the first phase, we determined the roles of the healthcare teams involved in the management of a COPD patient. This included the respiratory consultant and specialist, medical officers, the head nurse, staff nurses, pharmacist, dietitian, physiotherapist, and social worker. The clinical management of COPD was based on GOLD [12] and NICE [13] guidelines, as well as local best practices [1], but team members were allowed to deviate from the pathway depending on the clinical progress of the patient. We used this as a framework to decide on optimum days in the ward, the usage of oxygen therapy, antibiotic requirement and regimes, DVT prophylaxis and others. As a baseline, the expected length of stay was set at 5 days.
The COPD CP consisted of day-to-day assessment of the patients starting from day 1 until the day of discharge. These assessments included physiotherapy assessment, oxygen requirement assessment, treatment regimes; bronchodilator therapy corticosteroid and antibiotic requirement, deep venous thrombosis (DVT), fluid regime, blood tests and chest radiograph requirement were also listed in the assessment chart in the CP .
In the second phase, a pilot study was carried out to evaluate the feasibility of the COPD clinical pathway, and to modify the pathway accordingly Prior to starting the pilot study there was an official launch of the clinical pathway at the hospital level. This was officiated by the director of the UKMMC and attended by representatives from nurses, physiotherapists, pharmacists as well as medical doctors. A separate session to introduce the CP to the medical department was done as a continuous medical education (CME) session to the medical officers, house officers, nurses, pharmacists and physiotherapists who were based in the medical wards. The CME session was done to explain the clinical pathway in brief and outline the main roles to be played by each unit. In the third phase, we implemented the COPD CP in the medical wards in June 2009.
Piloting of the care pathway in subsets of patients
Patients admitted to the medical wards with a diagnosis of exacerbation of COPD were screened within 24 hours of admission and managed according to the COPD CP if the patients fulfilled the inclusion/exclusion criteria. The CP worksheets were attached to the patient's records, and to ensure compliance to the CP, we designated one study investigator (medical officer) to review the clinical pathway records daily and prompt the team to follow the specific goals set for each day. The study investigator performed daily ward rounds to enforce compliance on the usage of the pathway. The health care providers were given encouragement and reinforcement to implement the clinical pathway. Additional educational activities were also given to address specific issues raised during the implementation.
Evaluation of COPD CP
The evaluation focused mainly on the care process and outcomes. The variables that were measured for evaluation were length of hospital stay (LOS), complications or morbidity, readmission and mortality. Confounders of LOS would include smoking status of patient, hospital acquired infections, and worsening of co-morbidities.
In this study readmission was defined as any unplanned hospital admission within 30 days after discharge. Patients were given the status of readmission only if they were admitted for clinical problems primarily related to the initial episode of COPD exacerbation. The interval of follow up was 30 days and this was done via a telephone call. Complications were defined as any disease or injury that developed during the treatment of a pre-existing disorder. It can vary from complication related to the pre-existing disease or non related.
Statistical analysis
Sample size determination was calculated using Power and Sample Size Program (PS) package (version 3.0.43). Statistical comparisons were performed using Statistical Software Statistical Product and Services (SPSS) software package (version 19) using appropriate statistical tests at a significance level of 95%.
Recruitment and baseline characteristics
The CP group was prospectively recruited from a total of 212 patients that were admitted with a diagnosis of COPD exacerbation between June 2009 and December 2010. Ninety-seven patients fulfilled the inclusion criteria and all were recruited in the CP group (46%); 95 patients completed the study (98%). For the historical non-CP control group, the medical case notes of 281 COPD patients admitted between January 2008 and January 2009 were reviewed. Only 160 patients had complete documentation of the case notes, and of these, 98 patients fulfilled the criteria and were included in the control group (61%).
Baseline characteristics and demographic data between two groups
Total N = 193
Non-Clinical Pathway (n = 98)
Clinical Pathway (n = 95)
Age (years ± sd*)
68.48 ± 8.84
68.78 ± 8.45
68.18 ± 9.27
Gender [n(%)]
168 (87.0)
82 (83.7)
86 (90.5)
25 (13.0)
16 (16.3)
9 (9.5)
Ethnicity [n(%)]
51 (26.4)
25 (25.5)
26 (27.4)
110 (57.0)
61 (62.2)
49 (51.6)
29 (15.0)
11 (11.2)
18 (18.9)
3 (1.6)
1 (1.1)
2 (2.1)
Level of education [n(%)]
No formal education
31 (16.1)
18 (18.4)
13 (13.7)
94 (48.7)
54 (55.1)
40 (42.1)
68 (35.2)
26 (26.5)
42 (44.2)
Working status [n(%)]
37 (19.2)
15 (15.5)
22 (23.2)
Not working
156 (80.8)
83 (84.7)
73 (76.8)
BMI in kg/m2 (range)
24.4 (20.9–27.2)
24.6 (21.5–27.5)
23.8 (19.1–27.0)
BMI category (%)
Underweight (<18.5)
24 (14.4)
5 (6.9)
19 (20.0)
Normal (18.5 – 22.9)
42 (25.1)
23 (31.9)
19 (20.0)
Overweight (23 – 27.4)
67 (40.1)
26 (36.1)
41 (43.2)
Obese (>27.4)
32 (20.4)
18 (25.0)
16 (16.8)
Smoking status [n(%)]
Current smoker
22 (11.4)
17 (17.3)
5 (5.3)
171 (88.6)
81 (82.7)
90 (94.7)
Stage of disease [n(%)]
Stage 2
7 (4.0)
4 (4.8)
3 (3.4)
Stage 3
46 (26.6)
22 (26.2)
24 (27.0)
Stage 4
120 (69.4)
58 (69.0)
62 (69.7)
Co Morbidity [n(%)]
83 (43.0)
38 (38.8)
45 (47.4)
110 (57.0)
60 (61.2)
50 (52.6)
Types of Co morbidity[n(%)]
91 (47.2)
49 (50.0)
42 (44.2)
Diabetes Mellitus
37 (19.2)
18 (18.4)
19 (20.0)
Ischemic heart disease
52 (26.9)
28 (28.6)
24 (25.3)
48 (24.9)
26 (26.5)
22 (23.2)
Chronic kidney disease
10 (5.2)
5 (5.1)
5 (5.3)
Next we examined baseline characteristics of BMI, smoking status, COPD stage, and co-morbidities (Table 2). No differences were noted in the COPD stage of disease and presence of co-morbidities (p > 0.05) between the two groups. However, the CP group had significantly more underweight patients compared to the non-CP group (20% vs 6.9%) (p = 0.029). When we examined the smoking status, all patients had a history of smoking in both groups, but the non-CP group had a higher percentage of current smokers compared to CP group (17.3% vs 5.3%) (p = 0.008).
Evaluation of clinical outcomes
Length of stay (LOS)
Comparison of non-CP and CP group with average length of stay (ALOS)
Non-Clinical Pathway (n = 98)
Clinical Pathway (n = 95)
Average length of stay in days (LOS)
7.31 ± 2.75
5.83 ± 1.92
*Median LOS in days
7 (7–9)
5 (4–7)
Complication rates
Type of complications and readmission between groups
Non-Clinical Pathway (n = 38)
Clinical PathwayPValue (n = 14)
Type of complications (n)
Acute respiratory failure
Hospital Acquired Pneumonia
Acute Coronary Syndrome
Congestive Cardiac Failure/
Fluid overload
Acute Renal Failure
Upper gastrointestinal bleeding
Urinary tract infection
Readmission (< 30 days)
76 (77.6)
73 (76.8) *0.907
22 (22.4)
22 (23.2)
The commonest complication was acute respiratory failure leading to noninvasive positive pressure ventilation (NIPPV) or invasive positive pressure ventilation (IPPV) in both groups followed by hospital acquired pneumonia (HAP). Other complications were acute coronary syndrome (ACS), congestive cardiac failure (CCF) or fluid overload, acute renal failure (ARF) thrombophlebitis and cellulitis upper gastrointestinal bleeding (UGIB) urinary tract infection (UTI) and others, which include uncontrolled hypertensive and diabetes, acute gouty arthritis and stroke. (Table 4).
Number of readmissions
There were a total of 44 patients readmitted within 30 days of discharge. There was no difference between in the number of readmissions between the groups: 22 (22.4%) in non-CP group and 22 (23.2%) in CP group (p > 0.05).
Mortality rates
There were two deaths in the CP group (2.1%) and none in the non-CP group (0%). This difference was not significant (P = 0.24).
In this study, we developed and implemented a clinical pathway for the management of COPD exacerbations, and compared the outcomes (LOS, complication rate, readmission rate and mortality) of patients managed with the COPD clinical pathway with patients previously managed using the standard care guidelines.
As a baseline for comparison, we used historical controls from patients that were most recently managed using standard care guidelines one year prior to implementation of the clinical pathway. This control group was comparable to the patients that were prospectively recruited in the clinical pathway group: both groups had similar access to drugs, pulmonary rehabilitation, and smoking cessation clinic sessions; and their demographic profiles were similar. We did not find significant differences in the age, gender, and ethnicity between the groups.
The median BMI of the study population was 24.4 (20.9–27.2) which is classified as overweight following the Malaysian obesity guidelines (MOH 2004). Sixty one percent of the patients were overweight and obese, while 25.1% had normal BMI and 14.4% were underweight. Rampal et al. 2007 showed that the overall national prevalence of obesity in Malaysia was 11.7% [14], however, we noted that they classified the cut-off point of obesity as BMI ≥ 30 kg/m2. We classified obesity as a BMI ≥ 27.5 kg/m2 as recommended by the Malaysian clinical guidelines in management of obesity 2004[15].
A total of 171(88.6%) subjects were ex-smokers and 22(11.4%) were still actively smoking. There were more active smokers (17%) in the non-CP group compared to CP group (5.3%). This may have contributed to the differences in LOS between the groups. It is unfortunate that we failed to match this factor between the groups. The CP group had their smoking history taken with the knowledge that they were participating in a clinical trial. There is a possibility that they may have under reported their years of smoking. The historical controls from case notes had smoking history taken and verified over a few entries. This may have been more reflective of an accurate number of pack years and smoking status. However there was no significant association between smoking history and length of stay in the two groups. The study also found no significant association between smoking history and complication. When we removed the 22 current smokers and reanalyzed the data, the length of stay between the CP and non-CP group was still significant (p < 0.001).
In terms of severity of COPD, majority of the patients admitted for COPD exacerbation had moderate to severe stage of disease. This is in keeping with the role of UKMMC as a tertiary referral centre. Another possible reason is most COPD patients approach their doctor at a later stage of the disease.
As COPD patients are generally elderly, comorbidities are expected to be higher. More than 50% of COPD patients in this study had at least one comorbid disease. The most common comorbid disease was hypertension. A large study by Mannino et al. (2008) reported that lung function impairment was associated with more comorbid disease [16]. The risk of hospitalization and mortality were increased with comorbid disease, in which the mortality was worse in patients with impaired lung function [16]. Prevalence of diabetes was found to be increased in COPD where 15% of the patients with COPD admitted to the hospital had diabetes mellitus [16]. This result was almost similar to the prevalence of diabetes in our COPD population (19.2%). Antonelli et al. (1997) found that selected comorbids including chronic renal failure and myocardial infarction or ischemia were able to predict mortality in patients with advanced COPD [17].
This study confirmed our hypothesis that usage of CP in the management of acute exacerbation of COPD decreased the hospital length of stay (LOS). We found a significant reduction in LOS of the CP group as compared to the non-CP group. The overall median LOS of COPD patients was 6 days and ranged between 2 to 13 days. The median LOS in non-CP group was 7 days whilst the LOS in CP group was 5 days. A Study by Celis et al. (2004), which utilized the COPD CP, also showed a significant reduction of mean hospital stay of 13.21 days in the control group and 10.24 days in the CP group [18]. A similar study by Santamaria showed shortening of 0.89 days (13.2%) of hospital stay in the pathway group; however, this was not statistically significant [9]. This was a prospective unblinded study in a single unit and the non-CP group had more co-morbidities. This could have contributed to the LOS being not significant. A retrospective study by Celis et al. (2004) also did demonstrate a significant decrease in LOS [18], possibly due to the retrospective nature of the study.
For other respiratory disease CPs, Bailey et al. (1998) showed that the use of CP in asthma also caused reduction in the LOS [19]. This reduction in LOS was also noted after implementation of pneumonia clinical pathway [20, 21].
There is insufficient data to indicate the optimal duration of hospitalization in patients with COPD exacerbation. A study on necessary length of hospital stay for COPD done by Mushlin et al. (1991) found that 6.9 days was considered averaged LOS [22]. Our overall (both non-CP and CP groups) mean LOS was 6.56 days. We developed a 5-day COPD CP based on the recommended average use of antibiotic (3 to 7 days) from GOLD guidelines. Our CP was similar to COPD CP from the Grey Bruce Health Network in this aspect (approximately 5 days target). This study showed that CP can help in reducing length of stay and indirectly reducing cost of care.
The non-CP group had significantly more complications than the CP group (38 vs. 13). This is consistent with the study by Santamaria et al. (2004) which also showed fewer complications in the CP group [9]. Acute respiratory failure (14 cases) was the most common complication seen which is similar to the study by Santamaria et al. (2004) [9]. COPD patients are prone to develop type II respiratory failure with CO2 retention which would lead to mechanical ventilation support.
The number of readmissions was similar in both groups. We found no significant difference in the number of unplanned readmissions between the two groups. The main reason for readmission in this study was shortness of breath. The CP group also had longer readmission interval after discharge. Our findings were consistent with the study by Santamaria et al. [9]. The earliest unplanned readmission was four days in the CP group and one day in the non-CP group. There is an on-going study by the EUROPEAN Quality of Care Pathways Study on COPD (EQCP-COPD) looking at readmission rates as a primary outcome.
There was no significant association in mortality between the non-CP and CP groups. Our finding was similar to Santamaria et al. study [9]. There were two deaths in the CP group. Both patients were in stage IV COPD. One was a 70-year old male ex-smoker who had hypertension and ischaemic heart disease. The second subject was an 81-year old male who had no comorbidities. Both deaths were associated with COPD exacerbation.
We encountered minimal initial resistance to the clinical pathway. However, this was not a major issue. This lack of acceptance resulted in some deviation from the clinical pathway. Several batches of medical officers and house officers were rotated into the medical unit during the duration of this study. Information on the COPD clinical pathway may not be well disseminated. Our briefing sessions should have been more regular to improve the compliance and adherence to the CP. In our study it was not possible to screen admission during long weekends or public holidays. We designated a single investigator to review and prompt the doctors. This problem can be improved by appointing case managers in each ward. Due to the retrospective nature of case control section of this study, there were a number of incomplete data documentation and recording.
This study on COPD clinical pathway in Malaysia showed a decrease in LOS and complications. We are currently evaluating the effectiveness of the CP using this current data from a cost analysis point of view. This will be published upon completion of analysis. We continue to improve our COPD clinical pathway by studying the variances. We will use these to tailor the current CP to reflect our resources available to us.
In conclusion we have developed and implemented the first clinical pathway for inpatient management of acute COPD exacerbation in Malaysia. Our study suggests that the usage of CP in the management of COPD exacerbation decreases the hospital length of stay and complication rates. The clinical pathway integrates the routine assessment of a COPD patient. This can help identify patients at risk of pseudomonal infections and streamline their antibiotic therapy. In our study doctors were prompted to change antibiotics as well as steroid therapy to the oral form from day 2 of admission. Doctors were also prompted to switch to regular bronchodilator therapy MDI from day 2 of admission. There was a clear discharge plan listed in the clinical pathway. These factors may have contributed to a shorter length of stay in hospital.
We recommend its usage in other public hospitals in Malaysia to improve the efficiency and quality of care in COPD.
We are grateful for the cooperation given by UKMMC for allowing us to proceed with this study. A special thank to the University Kebangsaan Malaysia for approving the grant for this study. We wish to acknowledge all doctors and medical staff for giving the fullest cooperation for this study.
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2466/12/27/prepub
Pre-publication history
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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Sunday, August 11, 2013
Turtle Power!
6 comments:
- Mark Rodriguez said...
One reason might have been because they could have just been looking at the Playmates toyline and not the actual series. For whatever reason, the toyline called it Retromutagen Ooze.
- 8/11/2013
Ah, the only time you'll ever see Krang in a Mirage TMNT comic. Even if it was a story made up by a kid, its refreshing to see Krang actually *did* make it into a Mirage published TMNT comic at some point.
- 8/11/2013
But we got to see hundreds of Krang's cousins already way before ;)
- 8/12/2013
- Adam Winters said...
Krang, the evil brain from Dimension X, did make at least one other official appearance in the Mirage Comics taht I remember.
In the multi-verse 2-page spread in Tales of the TMNT Volume 2 #58!
- 8/12/2013
Wait a second, what happened to the Dreamwave comics?
- 8/12/2013
The dog mutant looks exactly like Rahzar, and Krang was actually planned to make an appearance in 'Secret Of The Ooze', so perhaps Hedden & McWeeney worked from drafts? Or they just tied into a bunch of different continuties. Obviously, 1991 was the height of Turtlemania, so I'd like to think of the story as a wink to the entire franchise.
- 8/14/2013


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Author Notes: This preserve starts with a pound of ripe strawberries and a pound of slender rhubarb stalks. Macerated with sugar and boiled until thick and spreadable, it's a terrific way to preserve the flavors of early spring. —Marisa McClellan
Makes: 3 half pints
pound strawberries
pound rhubarb stalks
1 1/2
cups granulated sugar
In This Recipe
- Wash the strawberries and rhubarb well. Hull the berries and dice them into small pieces. Chop the rhubarb into segments approximately 1/2 inch in size.
- Place the chopped fruit in a glass or ceramic bowl and cover with sugar. Stir to combine and cover. Let the fruit sit for at least an hour, until the juices are flowing.
- When you're ready to cook the jam, prepare a small boiling water bath canner and three half pint jars and bring it to a boil. Place three new canning jar lids in a small pot and bring them to a bare simmer.
- Pour the fruit and all the liquid into your jam pot and place it over high heat. For these small batches, I like to use a 12-inch, stainless steel skillet, but any low, wide, non-reactive pan will do.
- Bring the fruit to a rapid boil and stir regularly. Over high heat, this jam should take 8 to 12 minutes to cook. It is done when it is quite thick. You can tell that it's ready when you draw your spoon or spatula through the jam, and it doesn't immediately rush in to fill that space. It will also make a vigorous sizzling noise when stirred when it is finished.
- Remove the jam from the heat and funnel it into the prepared jars. Wipe rims, apply lids and rings, and process in a boiling water bath canner for 10 minutes (start your timer when the water returns to a boil, not the moment the jars go into the water bath).
- When time is up, remove jars from canner and set them to cool on a folded kitchen towel. When they are cool enough to handle, remove the rings and test the seals by grasping the edges of the lid and lifting the jar an inch or so from the countertop. If the lid holds fast, the jars are sealed. Any unsealed jars should be refrigerated and eaten promptly.
- This recipe is a Community Pick!
More Great Recipes:
Condiment/Spread|Fruit|Jam/Jelly|Rhubarb|Strawberry|5 Ingredients or Fewer|Spring|Breakfast


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New students can complete the New Student Orientation online
» View "New Student Orientation" online
Once complete, go to the Advising Center webpage for further information on registering for classes.
For directions logging into Blackboard, please refer to the gray "Information About Your Online Services" brochure located in your shiny white folder. If you experience problems logging into Blackboard, please call (828) 327-7000, ext. 4444 for assistance.
CVCC, (828) 327-7000, ext. 4216


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Use a Debt Management App
There seem to be mobile apps available for everything, and this includes for debt payment schedules and debt management. There are multiples apps designed for this purpose, and you can easily explore the options to find one that is most effective for how you manage your funds. Many will allow you to track debt payments, receive payment reminders, monitor debt reduction and more. Such useful features can help you to take your debt payment schedule to the next level. The first step to take when using most apps is to carefully list out each debt that you own as well as the monthly payment, interest rate and outstanding balance.
Set Up Automated Payments
While debt management apps are effective for some people, others prefer to set up their own automated plan. Most banks now offer bill payment services. You can create automated payments for each account you are responsible for on a recurring basis. You can easily schedule a regular amount to be paid and a specific day of the month for the debt to be paid. You can also easily adjust these as needed, and you can monitor payment activity with ease. This is the perfect way to ensure that all debts are paid on time each month.
Set Up Automatic Drafts
Another idea is to set up auto drafts directly with the creditor or lender. Some lenders provide you with the opportunity to break a large payment up into two smaller payments during the month. Many do not charge a service for this option. If your bank charges a fee for bill pay functionality, automatic drafts made directly to a lender are a better option. However, keep in mind that it can be much more difficult to adjust payment amounts and dates through this option.
Many people will need to work hard to achieve a debt-free status. They often need to take a slow and steady path by making regular payments each month and by avoiding taking on more debt. It may take several years or longer to accomplish your goal, but rest assured that success can be yours when you follow the right debt payment schedule and elimination strategy.


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NHTSA Head Seeks to Prevent Tire Blowouts on Big Rigs from Speed
The tires on big rigs probably aren't safe enough on highways with 80+ mph speed limits. That's the message brought to us by Meghan Barr and Tom Krisher with the Associated Press. According to Barr and Krisher, the nation's "safety chief," Mark Rosekind of the National Highway Traffic Safety Administration, wants to cap big rig speeds before a tire blowout causes a serious wreck.
Greater Risk of Tire Blowouts
Based on the AP report, the tires on big rigs aren't rated for speeds above 75 mph, yet many states have higher speed limits. In Texas, for instance, the speed on some rural highways is 80 mph or higher, which likely increases the risk of a blowout.
It's tough to tell how much of this is a manufactured news story, however, or simply busywork created by the NHTSA, as Barr and Krisher quote the NHTSA chief as having said that there haven't been any actual deaths tied to higher speed limits and lower rated tires. But we'd have to agree with the quote: "You don't wait for somebody to die when you know there's a safety problem there."
Other Factors
The AP reports cites the presence of other factors that may contribute to tire blowout, other than the tires not being rated for 80+ mph speeds - that of under-inflation or heavy loads, which could definitely be a cause for concern in terms of wrecks.
Speed Limiting
One of the NHTSA's options, apparently, is a speed-limiting device that would cap big rigs at 75 mph. If the NHTSA managed to push this through, as the NHTSA chief has said he'll do, that might be the best option of all, as reduced speeds in general would probably help prevent some wrecks.


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Ichiro holds all the leverage
Turns out Ichiro Suzuki, enigmatic international sporting icon that he is, is not much different than the typical Mariners fan. He, too, is sick of losing.
Lucky for him a divorce and new start is possible via free agency. The only choice for fans is to scratch their eyeballs out and run screaming through the streets if the home team is impaled by the rest of the American League West for a fourth consecutive season.
The breaking news Tuesday wasn't so much that Ichiro is contemplating bolting Seattle but that he spoke about it openly and clearly -- through an interpreter, of course -- and without the haikus, riddles and circular responses he typically employs.
"If you ask me 'Is it possible that I might become a free agent?' I would say 'Yes, it is possible,' " he said.
What, no musing about a metaphoric tree with neglected roots, see his 2006 All-Star Game media session?
This shouldn't be the least bit shocking. It's logical, really. An elite and competitive athlete pushing toward the twilight of his career sees one hole in his résumé -- a championship. He wants that void filled. He starts to suspect his organization isn't capable of putting together a team that will win one anytime soon. So he contemplates greener pastures.
Beyond that, this was a strategic announcement. Ichiro and his agent, Tony Attanasio, orchestrated this national story to deliver maximum impact with banner headlines across the state as spring training begins. That gives them juice as they negotiate over a new contract.
At present, Ichiro, 33, has all the leverage. He is Mr. Mariner -- Mariner-san -- the lone star connecting the magic of 2001 with the dreary present. His departure would be dispiriting to an already frustrated fan base, and their ire would fall upon management and likely eclipse the reaction to previous dispatching of superstars because Ichiro won't be freighted with a share of the blame. He cast aside his selfish reputation when he (finally) agreed to move from right field to center last summer.
The larger meaning of Tuesday's news, however, is that the July 31 trading deadline now looms over the season, particularly if Ichiro decides, as he has indicated, to wait and see how the team performs instead of signing an extension ASAP, as management is on record wanting to do.
If the Mariners are contending, Ichiro won't be traded and an extension could be signed during the season. If they aren't, there will be no re-signing -- based on what Ichiro and his agent said this week -- and it would be foolish not to entertain trade offers.
While it's difficult to imagine that trading Ichiro would inspire good will around these parts, doing so is eminently better than letting him walk away at the end of the season with a measly draft pick as compensation.
An Ichiro trade, however, would be cataclysmic, with the ensuing storm causing other casualties. That would include manager Mike Hargrove and general manager Bill Bavasi receiving their pink slips, if that grim turn of events doesn't precede said trade. It's nearly impossible to imagine a scenario in which Bavasi and/or Hargrove would be back in 2008 if Ichiro isn't.
In other words, if Ichiro goes, then ownership will blow up management and (again) rebuild from the top down. Guessing how the present roster would emerge from that shock and awe would be largely speculative, but it's hard to believe a new regime wouldn't make significant changes.
That might be for the best, judging by the lack of general enthusiasm heading into this season. But it won't be much fun to return nearly to square one after flirting with becoming one of baseball's marquee franchises from 2000-2003.
Of course, the flip side is ... blind optimism, whatever the potential outcome (cue angelic chorus).
All things being equal, Ichiro would prefer to stay with the Mariners because he enjoys Seattle. Reclusive team owner Hiroshi Yamauchi, who has a strong relationship with Ichiro, also would prefer that he stay with the Mariners. That counts for a lot.
Then there's the contrarian position: Trading Ichiro for a handful of elite prospects might provide a faster return to respectability. So both parties could benefit.
Finally, it's not ridiculous to believe the Mariners can, in fact, contend in the West, a division that is best handicapped by rating the various grades of mediocre. Heck, the World Series champion won 83 games last season, just five more than the Mariners.
As always, winning solves everything, and a fast start could prove critical. Falling into the division basement in May could make the larger questions concerning the franchise a distraction inside the clubhouse. Folks could refuse to talk about the status of Hargrove, Bavasi and Ichiro, but that doesn't mean responsible reporters wouldn't ask about them.
If the Mariners are again piddling below .500, those will be the only interesting topics anyway.


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When you have already picked your wedding dress, a new issue comes up. What kind of hairstyle will emphasize the beauty of your dress and complete your look? Choosing the right hairstyle can become a tricky and tedious task to overcome. It can be really difficult to match wedding hairstyles bridal dresses. But we want to assist you in solving this problem and picking the perfect variant for you. We create a list of the most appropriate hairstyle for specific wedding dress neckline. Pick the most suitable hairstyle from the list below.
Click NEXT PAGE below to browse the gallery!
Page 1 of 13


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Why in the world would you take that risk??jackknife wrote:I figured I would throw out another way of syncing the carbs...
I just use the 5mm adapters, a piece of clear vinyl tubing and some water. I put enough water in the tubing to fill about 2 feet of it. Then I lay the tubing over my handlebars so that the middle part with the water is hanging over the front and the ends are near the engine. I connect the ends to two carburetors at a time. By watching the level of water in the tube, it is easy to tell if one carburetor is pulling more vacuum than another.
In my personal opinion, this method tends to be more accurate than comparing mechanical gauges and safer than messing with mercury. It also doesn't hurt that it costs next to nothing.
It sounds way too risky to me.
What I am doing is taking from the "How to" method and instead of using four gauges I am using one.
I am using an aquarium "four way gang valve" http://www.petco.com/product/6239/PETCO ... alves-6239
and the other items Scott listed.
Then I do not need to calibrate my gauges and will have all four carbs still hooked up at the same time.
I am still waiting for the 5mm adapters to arrive-(I have plenty still to do before hand) but will take a photo when the come.
Messing with water near a carb. sounds like bad news waiting to happen


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Robotics Academy Certified Training for LEGO MINDSTORMS EV3 (Online)
This course requires LEGO MINDSTORM EV3 hardware and software (not included with tuition).
This course focuses on learning how to program the new LEGO MINDSTORMS EV3 robot, and how to navigate the new EV3 software. The course also covers how to use robotics as an organizer to teach CS-STEM (Computer Science, Science, Technology, Engineering, and Mathematics) concepts. A headset is highly recommended in order to participate in the course.
Our courses are designed around the National Research Council Next Generation Science Standards (NGSS), Common Core Mathematics Standards (CCSS), the College Board Computer Science Principles (CSP) Framework, and the International Technology and Engineering Educators Association (ITEEA) Standards. Attendees will have the opportunity to earn professional development credits and a Certificate of Completion by completing various assignments throughout the course.
This course is best suited for teachers and coaches with little or no programming experience who would like to learn both the fundamentals of EV3 programming and pedagogy associated with the accompanying STEM concepts. However, teachers with programming and robotics experience will find the class valuable for its focus on the EV3 language specifically, practice in troubleshooting student errors, and STEM integration aspects.
Session 1: Introduction- Course Concepts
- Pedagogy
- Course Logistics
- LEGO EV3 Education Programming Software
- Downloading and Running Code
- The Virtual Brick and CS2N
Session 2: Moving, Mathematics and Sensors– MINDSTORMS Hardware
– EV3 Programs
– Robot Math: Proportionality and Movement
– Movement and Turning
– MyBlocks
– Movement Challenges
- Touch Sensor
Session 3: Robot Sensors (Continued)
– What is a robot?
– Touch, Ultrasonic, Light, and Sound Sensors
– Program Flow
– Robot Decision Making: "Wait for…" Behaviors
– Sensor Challenges
Session 4: Decision Making
– Data Logging Investigation
– Loops
– Switches
– Repeated Decisions: Discrete
– Repeated Decisions: Continuous
– Obstacle Detection and Line Following
Session 5: Planning and Troubleshooting
– Troubleshooting for Student Understanding
– Planning, Pseudocode, and Process
– Search and Rescue Challenge
Data Flow
Displaying Data
The following items are required in order to take this course:LEGO MINDSTORMS EV3 Robot Kit – Sold Separately
– EV3 Core Set with Software Pack 5003400
LEGO MINDSTORMS EV3 Programming – Sold Separately
– EV3 Programming Software
Computer System Requirements
– Windows® XP, VISTA, 7, 8 or later / Mac® OSX 10.8 or later
– Internet Explorer 9.0 or later / Mozilla Firefox® 18.0 or later / Safari 6 or later
– Adobe Reader 7 or later (Adobe Reader 9 included for PC)
– Two available USB ports for robot and optional headset
– Broadband internet connection
Additional Materials
– Black electrical tape
– Hard, flat, blank surface approximately 4′ x 4′ in size.
– Yard or Meter stick
– Five 3″ tubes (e.g. toilet paper rolls, PVC pipes, etc…)
– Hardcover books (or other objects to act as obstacles)
– Plastic drink container ( or other containers)
– Colored items (to use with color sensor)
Tuition Cost - $599
Use the links to the top/right to register or checkout instantly.
Upon Completion
– ACT 48 credits / 36 hours per class (for Pennsylvania teachers only)
– Certificate of Completion of course 'graduates' – may be used to apply for Continuing Education hours
We will only use personal information (such as name, mailing address or e-mail address) contained in your registration or correspondence to respond to your questions or provide Robotics Academy updates. If you enter a chat area or post messages, remember that other users may have access to your email address and user name. The Robotics Academy will not share any personal information provided by you with any unauthorized person or company except where the disclosure is required by law or is necessary to comply with legal process.
Certificate of Completion Requirements
To earn the Certification, class attendees must complete all homework assignments to the satisfaction of the instructor and pass the certification exam.
Class Eligibility
Classes at the Carnegie Mellon Robotics Academy are available to individuals who are at least 18 years of age and minors who have parental consent to enroll. The Carnegie Mellon Robotics Academy reserves the right to restrict, suspend or terminate any student for violation of these policies. In consideration of your involvement with the Carnegie Mellon Robotics Academy, you agree to provide true, accurate and current information about yourself when you register. If you provide any information that is inaccurate or if the Carnegie Mellon Robotics Academy has reasonable grounds to suspect the information is inaccurate, the Carnegie Mellon Robotics Academy has the right to terminate your account.
Purchasing a seat to online classes gives access to one participant only. Resources distributed as part of the class are for use of the participant only. Purchase Orders are also acceptable. Please contact the Carnegie Mellon Robotics Academy at firstname.lastname@example.com for information about registering for the course, payment for the course, or if the course will be held. Please email if you have questions about the content of the course.
Internet Access / Bandwidth Fees
The Carnegie Mellon Robotics Academy is not responsible for any internet access or bandwidth fees you incur while taking this class.
International Export Controls
International enrollment is subject to applicable United States export controls and laws.
The Carnegie Mellon Robotics Academy will offer partial refunds for tuition expenses only if class registrants contact us prior to the beginning of the first class.
Copyrighted Class Material
All course documents are owned by the Carnegie Mellon Robotics Academy. These materials may not be reprinted in any form except those specified for instructional purposes. The course documents and presentations may be displayed and printed for personal, non-commercial use only. Only students registered for this course may access this material. The Carnegie Mellon Robotics Academy makes every effort to provide accurate and up-to-date content. However, we have no liability for the accuracy, content, or accessibility of the hyperlinks included with class material.
Use of Student Material
The Carnegie Mellon Robotics Academy reserves the right to use coursework done by students for the purpose of advancing the educational mission of the Academy. When this occurs, students will be given the option to have their name credited to the material. This includes, but is not limited to, text, graphics, multimedia and other material created as part of the Carnegie Mellon Robotics Academy online course assignments.
You agree to indemnify and hold the Carnegie Mellon Robotics Academy harmless from any and all losses, actions, controversies, suits, demands, claims, liabilities or any causes of action whatsoever. You expressly agree that the Carnegie Mellon Robotics Academy is not responsible or liable for any infringement of another's rights, including intellectual property rights.
Note: Policies are subjected to occasional revisions.


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You might think you have a little pilot on your hands because every time a plane flies overhead, he can't take his eyes off it. He loves the look and the sound. The large metallic machine intrigues most children. Your preschool child tunes in when he is interested, and an airplane theme provides a basis for activities that will develop his skill in math, language, science and creative arts.
Sorting is a math activity that most preschoolers enjoy. Buy a variety of plastic planes at a dollar store. and ensure they are safe for children. Give your child airplanes with limited attributes: large and small or red, yellow and blue. Let him decide how he wants to sort them so the activity is meaningful. Set out airplanes in a variety of sizes. Your child can arrange them from smallest to largest. He can count the planes: the number of blue and the number of red planes, for example, and tell you which group is larger.
Language Arts
Lots of colorful books in libraries and bookstores are about airports and airplanes. Read several to your child and talk about vocabulary words such as runway, flight attendant and pilot. Discuss flights your child has taken and ask where he'd like to fly. Paste a picture of a plane in the middle of a large sheet of art paper. Write the words "I wish I could fly to …" on the top of the paper. Find pictures in magazines or online of places your child would like to visit: Disneyland, the ocean, Grandma's house in Oregon. Use them to create a collage on the art paper.
An airplane contest is an enjoyable activity to do with family members or when your preschooler has playmates visiting. Make paper airplanes from different weights and sizes of paper. Your child can decorate his plane with stickers. Each contest participant stands at a designated spot and flies his plane to see which one goes the longest distance. Measure to find the winner. You can measure in footsteps and then use a ruler. Talk about which tool is more accurate for measuring and why the winning plane went farther.
What child doesn't love the airport? Take a field trip to the closest airport and talk about the sights and sounds. When you arrive home, set up an "airplane" with chairs. Your child is the passenger. Bring out a suitcase and have him think of the items he'd need to pack. He can look out the imaginary plane window and talk about what he sees. Enlist family members to act as the pilot, flight attendant and mechanic.
Borrow the melody to a well-known song such as "Twinkle, Twinkle, Little Star." Talk about words such as clouds, fly, take off, land, plane and sky. Make up lyrics to an airplane song and sing them to the famous melody. For example, "I'm an airplane, I fly high. Watch me take off to the sky." Your child will want to sing, dance and hold his arms out like an airplane.
Kids love to see their artwork on display. Give your child an airplane cut from heavy art paper. He can color or paint it with nontoxic paints, adding a door and windows. This type of activity develops his fine motor skills. Attach the plane to a string and hang it from the ceiling in his room.


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I think today we will take it pretty easy. We did get the catapult for them and saved that present to give them today so I am sure we will be having some serious catapult battles and reminiscing about our birthday party. I just love these little guys so much and I am pretty convinced they are the sweetest things on earth. They have made my life so very beautiful. Every single day they make me smile just by looking at their faces and make me belly laugh with all their hilarity and antics. I can't believe 5 years have passed already. It's been the best five years. Today is such a good day to celebrate. It's bittersweet sometimes watching your kids grow but it's the most amazing thing seeing who they become. I just gobble every minute. Happy birthday my little Luca Sparrow and wee Milo Pollux! xo
And if you are wondering that's a 'domo' cake, by request. Who is domo? I don't exactly know. But they were very excited. And Milo is the one in the pink shirt, Luca is in the baja.


text: Who can resist puffins with their large eyes, upright posture and bright orange beaks? The clowns of the ocean, puffins spend most of their lives in the north Atlantic, coming ashore for only a few months of the year to breed and raise their chicks. In her first book for children, scientific illustrator Zecca describes and illustrates this process in clear simple language and invitingly detailed gouache-and-colored-pencil illustrations, each a double-page spread. Beginning with the moment when the puffin mates reconnect, she goes on to explain how they prepare their burrow, incubate their single egg and feed the puffling after it hatches until it can take off into the ocean on its own. In an afterword strikingly different in style and tone, Stephen Kress, the director of Project Puffin, reminds readers (or, more likely, the adults presenting the book) of the threat of ocean pollution and global warning and need to support conservation issues; describes his program of puffin restoration in general terms; and points readers to the project's website. (Picture book/nonfiction. 7-10. Younger for reading aloud)


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Improving your business-critical apps is an ongoing concern. Centralized visibility and on-the-fly agility are crucial to providing excellent user experiences and enabling high employee productivity. But network and application monitoring solutions are often expensive and labor-intensive. Trends such as mobility, virtualization, and cloud computing complicate things further. How do you monitor and fine-tune your apps in a way that works for your organization, your customers, and your bottom line?
Learn how
Citrix Networking Insight Center is the answer. Supported by both Citrix ADC and Citrix SD-WAN, the network and application traffic monitoring platform helps businesses gain visibility across the entire organization, including web traffic, WAN conditions, potential security threats, and user experience issues on virtual desktops.
Citrix Networking Insight Center provides big data analysis without massive data collection networks, storage infrastructure, or multiple analytic tools.
With Citrix SD-WAN, Insight Center allows administrators to gain unparalleled visibility into Citrix Virtual Apps and Desktops environments, as well as other enterprise applications, on a hop-by-hop basis across the WAN network and in branch locations. No other WAN optimization solution can do this.
Insight Center is a high-speed application flow collector combined with tools for monitoring, analyzing, and reporting traffic and performance metrics. HDX Insight technology allows administrators to view reports on Citrix Virtual Apps and Desktops delivery from a variety of entry points with multilevel drill-down capabilities. Administrators can pinpoint the actual source of any ongoing or potential issue, and then transform raw data into action items.
Insight Center can monitor, marry, and parse network- and application-level traffic data. This gives IT the unique ability to troubleshoot individual performance issues at the most granular level. And this coverage goes well beyond the traditional desktop to include virtual desktop and application solutions that leverage the ICA protocol, as well as enterprise, web, mobile, cloud, and SaaS applications.
Both Citrix SD-WAN and Citrix ADC are supported by Citrix Networking Insight Center. Insight Center can be deployed as a virtual appliance, with no need for specialized hardware or complex configurations. This eliminates network sprawl, saving you money and real estate.
Citrix ADC
Citrix SD-WAN


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Aphorism #391.
"honesty is the best policy"
See Also:
home is where the heart is
honey catches more flies than vinegar
As always, please comment if you have any further analysis of this particular aphorism (or if you disagree with my analysis) – or if you have a good story!
Popularity: -0% [?]


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It appears that I have decided to start a blog on a whim. This is pretty unlike me. I only thought about it for a few days. A few days is the definition of a whim for a person like me. I am not a writer and I don't have perfect grammar. I'm not a fashionista or a master chef or an entrepreneur or a photographer or a social media user....the list could go on. I AM a young woman living in Toronto trying to combine my city life with my inner domestic homemaker. I am an avid DIYer and I tend to ramble. I love a good project..hopefully I follow through with this one.
Follow my blog with Bloglovin
<meta name="p:domain_verify" content="c4ab1630834feffd6ecb9dff781f1679"/>


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Here's the family banner:
Here's the spooky banner and a decorative frame I made with the extra supplies.
More to come on that...
I also made a few cards using the new coaster board. Love that its thicker than card stock but not too bulky. I used the Gorgeous Grunge set which is one I waited very patiently for! Love the versatility of it! Hope u like it!