text:
Traditionally, clearing firms have helped independent broker-dealers by ruling the back office. Now these durable companies are stepping out front by tuning BDs in to vital growth opportunities—as well as to potential perils.
Their expansion is all part of the accelerating evolution of clearing firms from providers of basic execution, custody and reporting services to muscular guides helping BDs grow and flourish in these challenging, competitive times.
Just a few issues clearers are bringing to the surface include how BDs must be ahead of the curve to counter ongoing low interest rates, the pressing need for risk management of every sort and how to embrace today's—and tomorrow's—changing investor.
"All clearing firms have the ability to process trades, and the technologies behind that are not all that different. It's service that goes above and beyond that differentiates clearing firms. This is critical," says Robb Combs, director of correspondent clearing, Raymond James & Associates, based in St. Petersburg, Fla.
Such service can take the form of a clarion call for BDs to take their heads out of the sand. With interest rates continuing at unprecedented lows and the likelihood of a rise in the next year or two a fantasy, correspondent clients must focus on what this means to their clearing-firm relationship.
Indeed, clearers historically have derived one-third of their revenue from interest. But for at least the last four years, this revenue source has been wiped out because of stuck-in-the-cellar rates. Something's gotta give. That's pricing—and it is on the ascent.
"Clearing firms' prices per trade are already starting to go up. In the next year or two, you'll see this as a big trend. The largest firms will start it. The cost of services will be driven up," says Craig Gordon, director of RBC Correspondent and Advisor Services, in Minneapolis.
He continues: "The message to broker-dealers is clear: If you're not planning for an environment with higher operating costs, you're going to miss the boat. If you're not the mouse that can find a new cheese—source of revenue—you'll be in trouble."
Gordon, a clearing industry veteran, foresees further cuts in services that are now part of firms' bundled pricing: e.g., fees for IRA accounts or the elimination of order desks.
"It's already started to happen," he says. "Independent broker-dealers are being asked to do more and/or pay more."
In this scenario, BDs, not surprisingly, are likely to pass increased costs to their FAs, who, not surprisingly, won't be thrilled.
"The reps will feel it in their pocketbook and say, 'I'm not going to take a pay cut!' So they'll pass it on to their clients," Gordon says. "It's unrealistic to think that clearing costs won't be going up. Step out of the forest! Firms that don't anticipate the change and the need to diversify their revenue source are going to be left by the wayside."
The two biggest clearers, Pershing and National Financial, with 1,500 and about 270 clients, respectively, maintain that they'll keep pricing stable.
Pershing's Jim Crowley, chief relationship officer, based in Jersey City, N.J., says, "I don't necessarily see [price hikes] in the crystal ball. It's not part of our plan."
National Financial's Sanjiv Mirchandani, president of the Fidelity Investments unit, headquartered in Boston, states: "We're committed to providing competitive pricing. I certainly don't see us moving away from that approach. Nor do we have plans to cut services."
Other clearing firms acknowledge that costs are rising but also insist they have no plans to raise prices.
"Clearing has been driven down to commodity-type pricing, and the dollars being spent by the firms are for additional tools to run your business," says Combs, whose unit has 42 clearing clients. "So, it's a logical assumption that prices will rise—but not by us."
The antidote to low interest rates and lost revenue is not to raise prices, says William Coppel, managing director and chief growth officer, First Clearing, based in St. Louis, which has 88 clients. "Raising prices to maintain your market share and position is a bad strategy. Rather, you've got to help [BD] firms grow. Focus on increasing the efficiency of your business so you have the capacity to serve more clients and drive your top-line revenue."
Female Focus
One smart way clearing firms are fostering client growth is making broker-dealers aware of the nation's changing demographics and how this affects their very livelihood. Some clearers have even become founts of knowledge on how to embrace the female investor and the tremendous opportunities therein.
These firms have funded white papers detailing how FAs can better tap into this fertile market by trying to psych out the female psyche.
Co-published by First Clearing and Cannon Financial Institute, "Women and Wealth: The Invisible Opportunity" combines the latest research along with practical advice for BDs and FAs.
The paper points out that: "Over the past 30 years, the number of working women has doubled. Women control about 33% of the wealth in North America. By the end of this decade, women will be in control of $22 trillion. Within three years of a husband's death, 70% of widows choose a different advisor." Despite all that, the paper says, women often report being "ignored and treated with condescension by the industry."
"Women and Wealth" goes on to state that because of "differences in the biology of male and female brains," women, in contrast to men, want "an ongoing relationship with an advisor who takes the time to get to know and truly understand their needs."
Says Coppel: "Affluent women want a personal relationship with their advisor. But that will be really hard for a lot of advisors because they have horrible interpersonal skills."
The paper concludes that most FAs need training to learn skills to develop "the right experience" for the affluent female investor."
"Our research," Coppel says, "is aimed at better preparing the advisor community to deal with the demographic phenomenon that is shifting wealth from what was largely a male-dominated population to what eventually will be a female-dominated population."
A white paper from Pershing, a BNY Mellon affiliate, is titled "Women Are Not a 'Niche' Market. They Are a Significant Business Opportunity." It points out that "about 80% of women will be solely responsible for household finances at some point in their lives." The research survey found that "women were more likely to engage with financial advisors than were men (46% vs. 34%)."
Notes Crowley: "Advisors need to shift their thinking. Whereas historically, the behavior has been to focus on the male, that is now a losing proposition for advisors inasmuch as women control a greater portion of the wealth, are going to control more of it and that there are more women in the work force than men.
Says Crowley: "The headline is: Advisors and broker-dealers need to be paying attention to the environment because it's changing very quickly, and the market is too volatile."
Last November, Fidelity Investments, of which National Financial is a unit, released its latest annual "Millionaire Outlook Series" research study on attitudes and behaviors of millionaire investors. Key findings concerning females include "indications that women are investing more conservatively than men and could benefit from investment guidance; more women are interested in holistic planning [versus] more men focused on greatest investment return" and that "women generally do not feel as wealthy as men even though the amount of household assets is similar." In addition, 77% of the women said that the most important benefit in working with an FA is it "helps protect my wealth."
"The rise of the woman investor cuts across all demographic groups"—seniors, boomers, generations X and Y, notes Mirchandani. "Women control 50% of the wealth in the country. And because of life expectancy, they are going to control more like 60% to 65% in just the next 10 years. Women-owned businesses are a huge rising force of the economy." He adds, though, that "women perceive the financial services industry quite negatively."
To help counter that, National Financial has launched a series of practice management tools to improve FAs' approach to women clients, stressing that female investor needs differ from those of men.
Beyond Transactions
Concurrent with big changes in the investor demo profile, no longer is the clearing industry your grandmother's clearing industry. That is partly a reflection of a shift in the entire financial services world and securities markets.
"It's common knowledge that the daily transaction count of all the exchanges is down significantly. This is redefining the space where we often measure growth and success based on the daily amount of retail transactions. That model is obsolete," Coppel says, "because it's now much more about asset management."
He continues. "An advisor compensated based on their advice is a very different model from a transaction-oriented advisor. This re-architects the landscape relative to clearing firms and brokerage firms. Therefore, as clients come back into the market, we have to look at how they're investing."
At the same time, as a result of the financial crisis and heightened consumer awareness, clearing firms are putting much more emphasis on risk management.
Pershing, for instance, has created technology for trade surveillance and sales surveillance, which are integrated into its offering and available on a variable-cost basis. The sales surveillance tool allows management to review advisor behavior in order to fulfill oversight responsibilities.
Raymond James earlier this year rolled out its new Supervisory Work Station, a system that gives correspondents a look at all aspects of their operation, for example by showing important trading and customer account parameters "to help run a clean business," Combs says.
To be sure, clearing firms themselves are taking on more responsibility for risk management. "It used to be simply plug-and-play, a processing business where it was up to the introducing firms to manage their own risk and supervision," Coppel notes. "Now it's everyone's responsibility to know who you're doing business with. All the firms are taking a much closer look at the folks they want to serve. It's very imprint to take nothing for granted and to look deeply into the type of business we're going to affiliate with or work with."
First Clearing's Protect Offering, part of the firm's basic clearing package, includes tools on how to navigate daily risk-management issues that have emerged as a result of Dodd-Frank.
Social Rules
Another super-timely matter that clearing firms are addressing is social media in the financial services arena. While this is something of a conundrum given compliance and monitoring requirements—still unclear—the hot new form of communication is here to stay and therefore warrants BD attention.
Though some broker-dealers are testing social media, it is still too early for the phenomenon to become mainstream in the industry.
"It's sexy to talk about because it's new, but it's treacherous waters to navigate because you've got all the regulatory requirements about what you can and cannot say, and how it has to be monitored," notes RBC's Gordon.
Virtually every National Financial client has been looking at social media, Mirchandani says. "But people are waiting for more clarity on the rules. Firms are definitely experimenting with it—writing blogs, getting on LinkedIn, Facebook, Twitter. Those are all things that good advisors are going to have to leverage to connect with their clients in the way they want to be connected. It's absolutely an important issue; but it's not necessarily ready for prime time."
Some Pershing clients have been trying out social media, but the clearer has yet to deliver pertinent tools. Yet, Crowley says, "our research tells us that you really do need to be paying attention to social media developments and thinking about what the behaviors of the future generation of investors and advisors will be and how social media will play a role. You have to have service to meet those behavioral changes."
Another issue, of course, is that the infrastructure, monitoring and record-keeping of social media participation will necessitate substantial financial investment. "We're interested in helping our firms navigate that," Coppel says, "but it will take some time before social media finds its appropriate level and effectiveness in the client-advisor relationship."
All in all, nowadays clearing firms are serving in a far more consultative capacity to guide clients through the choppy, often strange, waters of the 21st century.
"This is not a time for business as usual," Mirchandani says. "You have to start to get creative and really define your strategy."


text:
You'd be wrong.
To be fair, it did not inspire me to rage uncontrollably, nor did it make me feel like Randall was phoning it in, or reusing a tired, old joke. It just made me feel kind of...apathetic. My reaction was something like that. "What? Batman? What the he-oh wait. Two Face. I guess that's kind of clever." And that was it. The end. In the vocabulary of the online world, it was a very "meh" comic. To me, that's almost as sad as him just making a straight-up terrible comic. Why? Because, this time, it seems like he was honestly trying to make something original, interesting, and funny, and yet all it managed to inspire in me was apathy. I wish it had been terrible, because then I could rage about how much of a shitbox Randall's comic is. Hell, I wish it had been fucking amazing, so I could at least feign outrage and have a good laugh and rail against Randall for not putting out great work all the time while feeding him small compliments throughout the course of the post. Instead, I feel...nothing. I use anger as catharsis, but I have no rage within me with which to...cathart...but the reason this comic - which I really think had a lot potential - fell flat is painfully obvious:
The art.
This joke relies entirely on visual cues. Unless the visual similarity between Randall's self-insertion fanfiction version of himself and the actual DC villain Two-Face is uncanny, the joke will lose a lot of its humor. I'm not talking about instant realization of the punchline. I think it's fine for it to take a little while for "the funny" to sink in - delayed reactions can be hilarious if they're properly done. However, such a delayed reaction is only funny - especially in the realm of the visual - if said realization is accompanied by a strong image. Look at the following picture:
Does that look like Two Face to you? Even though the only distinguishing features are a column of red dots near the center of his face (not clearly to one side) and a coin being flipped (that is not two-headed and scratched on one side)? The mass of random dots in the middle of his face remind me more of Rorschach. The simple truth is that Randall did not clearly portray the two most iconic features of Two Face, the very villain about which he was trying to create a joke. I understand that the stick figure is supposed to be looking up and to the side (hence the "centering" of the "pimples"), but with the lack of any other facial features it makes the image less clear, and the joke is further diminished. The fact that I even had to think about why the acne looked like it was centered ruins the joke - if you have to spend time thinking about what the fuck it is you're even looking at, then a joke whose punchline is primarily visual is going to suck.
So, sadly, as good of a joke as this could have been, it is ruined by the fact that Randall is the one who made it. If he had sold this idea off to someone with even a modicum of artistic talent, it might have been funny. Instead, it just falls flat. Thanks for nothing, Randall.
I'm sure all of you have been inundated by links to Axe Cop already, but in the off-chance that any of you have yet to discover it, it is pretty much the best thing on the Internet and you should go read it immediately.

subset: commoncrawl


text: Thursday, March 14, 2013 Cost of Diabetes Increases 41% in 5 Years The total costs of diagnosed diabetes have risen to $245 billion in 2012 from $174 billion in 2007, when the cost was last examined, says the American Diabetes Association. This figure represents a 41% increase over a 5-year period. The study, Economic Costs of Diabetes in the US in 2012, includes direct medical costs of $176 billion, which reflects costs for hospital and emergency care, office visits, and medications; and indirect medical costs totaling $69 billion. Indirect costs include absenteeism, reduced productivity, unemployment caused by diabetes-related disability, and lost productivity due to early mortality. In addition, the study found that: Medical expenditures for people with diabetes are 2.3 times higher than for those without diabetes. The primary driver of increased costs is the increasing prevalence of diabetes in the US population. Despite the introduction of new classes of medication for the treatment of diabetes, antidiabetic agents and diabetes supplies continue to account for only 12% of medical expenditures in both 2007 and 2012. The research also examined costs along gender, racial and ethnic lines, and included state-by-state data. Key findings include: Most of the cost for diabetes care in the US, 62.4%, is provided by government insurance. The rest is paid for by private insurance (34.4%) or by the uninsured (3.2%). Total per-capita health expenditures are higher among women than men ($8,331 vs $7,458). Total per-capita health care expenditures are lower among Hispanics ($5,930) and higher among non-Hispanic blacks ($9,540) than among non-Hispanic whites ($8,101). The per-capita cost of medical care attributed to diabetes was $6,649 in 2007 and $7,900 in 2012, a 19% increase. Among states, California has the largest population with diabetes and thus the highest costs, at $27.6 billion. Although Florida's total population is fourth among states behind California, Texas, and New York, it is second in costs at $18.9 billion. The study will be published in the upcoming April issue of Diabetes Care.


text:
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Black stainless steel watch bandBarrel shaped caseStainless steel backJapan miyota movement made by CitizenBattery includedWatch band: approximately 15cmWatch case: approximately 3.8cm x 4.4cm Weighs approximately 109g
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text: © 2020 BlackRock, Inc. All rights reserved. BLACKROCK, BLACKROCK SOLUTIONS, BUILD ON BLACKROCK, ALADDIN, iSHARES, iBONDS, iRETIRE, iSHARES CONNECT, FUND FRENZY, LIFEPATH, SO WHAT DO I DO WITH MY MONEY, INVESTING FOR A NEW WORLD, BUILT FOR THESE TIMES, the iShares Core Graphic, CoRI and the CoRI logo are registered and unregistered trademarks of BlackRock, Inc., or its subsidiaries in the United States and elsewhere. All other marks are the property of their respective owners.


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text:
Chronic compartment syndrome (CCS) occurs when pressure builds up within the body's muscle compartments. Compartments are made of sheets of connective tissue called fascia. These sheets are under the skin of the arms and legs. They wrap around groups of muscles, nerves, and blood vessels. When pressure builds up in the compartments, it disrupts or blocks blood flow to the muscles and nerves.
Unlike acute compartment syndrome, CCS is not an emergency. However, you should see your doctor to get treatment.
Risk Factors
CCS usually occurs in people less than 30 years old. Other factors that may increase your chance of CCS include:
- Participating in endurance sports
- Participate in sports that involve running or jumping
- Anabolic steroid and creatine use
- Eccentric exercise
- Poor biomechanics in runners
CCS can affect the lower leg. However, it can also affect the arms, hands, feet, and buttocks. Symptoms may include:
- Severe pain during exercise that typically goes away an hour after stopping
- Pain on both sides of the body, such as in both legs
- Fullness or tightness in the muscle
- Tender, aching muscles
- Muscle weakness
- Numbness, tingling
- In severe cases, foot drop—a foot slaps hard on the ground when running
Your doctor will ask about your symptoms and medical history. A physical exam will be done.
Talk with your doctor about the best treatment plan for you. Treatment options include the following:
Surgery, called fasciotomy, is the main treatment for CCS. This is done to open the compartment and relieve pressure. A long cut will be made into the fascia to open the tissue and relieve pressure.
It can take up to 3 months to recover. After surgery, you will need physical therapy.
Nonsurgical Approaches
If you are only had CCS for a short time or you decide not to have surgery, your doctor may recommend that you:
- Stop the activity that is causing CCS and rest.
- Change your training routine.
- Do physical therapy.
- Take anti-inflammatory medications or muscle relaxants.
- Custom made orthotics.
To help reduce your chance of CCS:
- Avoid overexercising
- Change your training routine
- Avoid anabolic steroids and creatine
Revision Information
- Reviewer: EBSCO Medical Review Board Warren A. Bodine, DO, CAQSM
- Review Date: 11/2018 -
- Update Date: 12/20/2014 -


text: Thursday, January 31, 2013 New in the Literature: Treatment for ACL Tear (BMJ. 2013;346:f232) In a follow-up of a randomized controlled trial, a strategy of rehabilitation plus early acute anterior cruciate ligament (ACL) reconstruction did not provide better results at 5 years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear, say the authors in their article published this month in BMJ. This study included 121 young, active adults (mean age 26 years) with acute ACL injury to a previously uninjured knee. All patients received similar structured rehabilitation. In addition to rehabilitation, 62 patients were assigned to early ACL reconstruction and 59 were assigned to the option of having a delayed ACL reconstruction if needed. One patient was lost to 5-year follow-up. The main outcome was the change from baseline to 5 years in the mean value of 4 of the 5 subscales of the knee injury and osteoarthritis outcome score (KOOS4). Other outcomes included the absolute KOOS(4) score, all 5 KOOS subscale scores, SF-36, Tegner activity scale, meniscal surgery, and radiographic osteoarthritis at 5 years. Thirty (51%) patients assigned to optional delayed ACL reconstruction had delayed ACL reconstruction (7 between 2 and 5 years). The mean change in KOOS4 score from baseline to 5 years was 42.9 points for those assigned to rehabilitation plus early ACL reconstruction and 44.9 for those assigned to rehabilitation plus optional delayed reconstruction (between group difference 2.0 points after adjustment for baseline score). At 5 years, no significant between-group differences were seen in KOOS4, any of the KOOS subscales, SF-36, Tegner activity scale, or incident radiographic osteoarthritis of the index knee. No between-group differences were seen in the number of knees having meniscus surgery or in a time-to-event analysis of the proportion of meniscuses operated on. The results were similar when analyzed by treatment actually received.


text:
Charitable giving by ultrawealthy philanthropists has yet to recover from the 2008 economic shock, according to a study published last week by The Chronicle of Philanthropy.
The donors on The Chronicle's 2013 Philanthropy 50 committed a total of $7.4 billion to charity in 2012. The median gift was $49.6 million, down from the 2007 high of $74.7 million.
The report said most of the money went to brand-name institutions, with 72% of donor pledges supporting higher education, arts and culture, hospitals and private foundations.
Wealthy donors' support of institutions that have a record of securing big gifts have helped those groups weather the recession, according to the report. Columbia University, UCLA's School of Public Health and the Central Park Conservancy were among such beneficiaries.
More U.S. billionaires are starting to give away their fortunes even before they reach middle age, according to the study.
Three of the five top philanthropists last year were couples under 40. "Drawn to the possibility of influencing social issues for decades to come, the young and super-rich are turning philanthropy into a newlywed activity instead of a deathbed one," the report said.
It said some big donors were increasingly trying to support local issues and give to groups to which their names were not attached. Community foundations, for example, won eight gifts totaling more than $1 billion from top donors last year. That was more than in The Chronicle's previous 10 lists put together.
Concerns about state budget crises also prompted some of 2012's biggest gifts. With government-supported institutions losing state money, more donors seemed to be trying to fill the gaps.
Following are the top 10 ultrawealthy donors on The Chronicle's 2013 Philanthropy 50.
10. David Gundlach (deceased), founder of Hastings Direct, an auto insurance company
Total given: $140 million (bequest)
State: California
Source of wealth: Insurance
Beneficiary: Elkhart County Community Foundation
9. Sheldon Adelson, chairman of Las Vegas Sands Corp., a developer of resorts, and Miriam Adelson, physician
Total given: $143 million
Age: 79, 66
State: Nevada
Source of wealth: Hotels
Top beneficiaries: Dr. Miriam and Sheldon G. Adelson Medical Research Foundation and the Adelson Family Foundation
8. Carl Icahn, financier
Total given: $150 million
Age: 76
State: New York
Source of wealth: Investments
Beneficiary: Mount Sinai School of Medicine
7. Fred Fields (deceased), former owner and CEO of Coe Manufacturing Co.
Total given: $191.5 million (bequest)
State: California
Source of wealth: Manufacturing
Top Beneficiary: Oregon Community Foundation
6. Mortimer Zuckerman, co-founder of Boston Properties; chairman and editor in chief of U.S. News and World Report; publisher of the New York Daily News
Total given: $200 million
Age: 65
State: New York
Source of wealth: Media and entertainment, real estate
Beneficiary: Columbia University
5. Sergey Brin, co-founder of Google, and Anne Wojcicki, a biotechnology analyst and co-founder of 23andME, a genetic-testing company
Total given: $222.9 million
State: California
Age: Both 39
Source of wealth: Technology
Top Beneficiary: Brin Wojcicki Foundation
4. Paul Allen, co-founder of Microsoft
Total given: $309.1 million
Age: 60
State: Washington
Source of wealth: Technology
Top beneficiary: Allen Institute for Brain Science
3. John Arnold, founder of Centaurus Energy, a hedge fund, and Laura Arnold
Total given: $423.4 million
Age: 38, 39
State: Texas
Source of wealth: Finance
Top beneficiary: Laura and John Arnold Foundation
2. Mark Zuckerberg, co-founder of Facebook, and his wife, Priscilla Chan, a pediatrician
Total given: $498.8 million
Age: 28,27
State: California
Source of wealth: Technology
Beneficiary: Silicon Valley Community Foundation
1. Warren Buffett, Berkshire Hathaway
Total given: $3.1 billion
Age: 82
State: Nebraska
Source of wealth: Investments
Top beneficiaries: Howard G. Buffett Foundation, NoVo Foundation and the Sherwood Foundation
More Top 10 Lists from AdvisorOne:


text:
XO XO Art Print
Availability: In stock
Brand: LetterNote
- Unframed Art Print for your home or work space.
- Digitally printed on premium matt art paper
- Shipped worldwide in a sturdy mailing tube.
NOTE: The print is sold unframed. Please note that the frame shown here is not included in the sale., its for illustrative purposes only.
Please allow 10-15 days for delivery.
LetterNote creates graphic art and everyday objects infused with ideas and expressions to inspire joyful living.
- Does LetterNote take wholesale / retail orders?
Yes, we do. Contact us at firstname.lastname@example.com
- How long does it take to for my order to arrive?
We process all orders within 2-3 working days. Shipping can take between 5-10 working days depending on your location.
- Why have I received only a part of my order?
Based on the items that you have ordered, the availability and location of inventory, we may ship your order in parts. We will inform you when we are shipping your order in parts.
- How much does shipping cost?
Since shipping costs vary for products and locations, the best way to calculate is to add the items in your cart and calculate the shipping costs by
- Where do you ship from?
Depending on your location, we ship from our manufacturing and inventory locations in USA and India.
- Do you ship internationally?
Yes, we ship to over 50 countries around the world. If your country is not listed in our shipping options, please email us at email@example.com and we will try our best to get the products across to you.
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You would also get a confirmation email when your order is shipped with the order tracking details.
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Orders once placed cannot be cancelled / modified as we start processing the order as soon as it is received. Exceptions can be made at the sole discretion of LetterNote. Please contact us quickly if you want to cancel, or modify your order.
If you are completely satisfied with your LetterNote purchase, you can request a 100% full refund or store credits.
- How to I return an item and get the refund?
You can return any item in its original, unused condition within 15 days of delivery. Please email us at firstname.lastname@example.com or submit a request through our contact form. Once we received the items, we will process the refund. We do not cover the return shipping cost.
- Damaged Items
If you have received a damaged item, we will send a replacement at no extra cost. Please email us at firstname.lastname@example.com or submit a request through our contact form.
- Exceptions to our Return Policy
Items that are not in their unused, original state cannot be returned.
We work hard to get your orders to you pronto.
- For all orders delivery time is 7-10 working days.


text:
An above-the-knee amputation (AKA) is the surgical removal of the leg above the knee.
Reasons for Procedure
An AKA may be done because of problems in the foot or lower leg such as:
- Poor blood flow that cannot be fixed
- Severe infection
- Trauma or injury
- Tumors
- Congenital disorders, such as a limb that has not formed properly
Possible Complications
Problems from the procedure are rare, but all procedures have some risk. Your doctor will review potential problems, like:
- Skin breakdown at the residual limb
- Infection
- Poor healing of the amputation site that may require a higher level amputation
- Swelling of the residual limb
- Decreased range of motion in the hip joint
- Phantom limb sensation —feeling that the amputated limb is still there
- Phantom pain —feeling pain in amputated limb area
- Bleeding
- Blood clots
- Reaction to anesthesia
Before your procedure, talk to your doctor about ways to manage factors that may increase your risk of complications, such as:
What to Expect
Prior to Procedure
Your doctor may do any of the following before your procedure:
- Physical exam
- Blood tests
- Imaging tests, such as x-rays or scans
- Have you donate blood in case you need a transfusion
- Prescribe antibiotics to prevent infection
Before surgery, you will need to:
- Arrange for a ride home.
- Arrange for help at home while you recover.
- Talk to your doctor about any medications, herbs, or supplements you are taking.
- Ask your doctor about devices you will need after the surgery like an artificial limb, walker, crutches, and/or wheelchair.
Talk to the doctor about the medications you are taking. You may need to stop taking some medications up to 1 week before the procedure.
Do not eat or drink anything after midnight the day before your surgery, unless told otherwise by your doctor.
You may be given one of the following:
- General anesthesia —you will be asleep during the surgery
- Spinal anesthesia —you will be numbed from the waist down
- Regional anesthesia —this will numb your leg and the area surrounding it
Description of the Procedure
An incision will be made in the skin above the knee. Next, the muscles will be divided and the blood vessels clamped. A special saw is used to cut through the bone. The muscles are then sewn and shaped. It will form a stump that will cushion the bone. Nerves are divided and placed so they do not cause pain. The skin is closed over the muscles, to complete the stump. Drains may be inserted into the stump. It will allow blood and fluids to drain from the area in the first few days after surgery. A dressing and compression stocking will be placed over the stump.
How Long Will It Take?
Several hours, depending on your health and the reason for the surgery.
How Much Will It Hurt?
Anesthesia will prevent pain during surgery. There will be pain and discomfort after the procedure. It can be managed with medications.
Average Hospital Stay
The usual length of stay is 5-14 days. It is possible that you may have to stay longer if complications arise. You may also go to a rehabilitation hospital to help you recover.
Post-procedure Care
Right after the procedure, you will be in a recovery room. Your blood pressure, pulse, and breathing will be monitored. Treatment during recovery may also include:
- Pain medications
- Antibiotics to prevent infection
- Medication to prevent blood clots
Physical therapy often starts within 24 hours after your surgery. Devices will help you walk.
During your stay, the hospital staff will take steps to reduce your chance of infection, such as:
- Washing their hands
- Wearing gloves or masks
- Keeping your incisions covered
There are also steps you can take to reduce your chance of infection, such as:
- Washing your hands often and reminding your healthcare providers to do the same
- Reminding your healthcare providers to wear gloves or masks
- Not allowing others to touch your incision
When you return home, you will continue with physical therapy and exercise. You will be instructed on how to care for the wound. Medications may be prescribed to manage pain.
Adjusting to an amputation may be difficult. Some may have depression. Consider talking to a therapist or psychologist.
Call Your Doctor
Contact your doctor if your recovery is not progressing as expected or you develop complications, such as:
- Increased swelling in the residual limb
- Poorly fitting prosthesis
- Pain that cannot be controlled with the medications you were given
- Signs of infection, such as fever or chills
- Increasing redness, swelling, increasing pain, excess bleeding, or discharge from the incision site
- Persistent nausea or vomiting
- New or increased symptoms of depression
- New cough , shortness of breath, or chest pain
- Joint pain, fatigue, stiffness, rash, or other new symptoms
If you think you have an emergency, call for emergency medical services right away.
Revision Information
- Reviewer: EBSCO Medical Review Board Warren A. Bodine, DO, CAQSM
- Review Date: 11/2018 -
- Update Date: 06/12/2018 -


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Magnetic Picture Twister - Birds
Product Information
|Mix up the pieces and put them back to the start
|Level 5 - Easy
|Popular Playthings
|Other Misc Puzzles
Product Description
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Age: 4+
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They say a picture is worth a thousand words and that's where the puzzling fun begins with our Magnetic Picture Twisters. First just turn the eight magnetic puzzle wheels left and right to mix up the picture. Then reverse the process until all images are complete. Too easy? Now separate the wheels, mix them up and try again. Hidden magnets keep the wheels together while you try to solve the puzzle, making it ideal for travel!
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Proposed Uses:
The shiitake mushroom is native to Japan, China, and other East Asian countries, where it naturally grows on fallen trees in the forest: hence the common name, "black forest mushroom." Deliberate cultivation of shiitake, both for food and medicine, is of ancient origin.
During the Ming Dynasty period (1368-1644), shiitake developed a reputation as a "tonic," a substance said to increase energy, prevent disease, aid convalescence from illness, and slow bodily deterioration caused by aging. It was also used more specifically to treat respiratory illnesses, liver diseases, and intestinal infestation with worms.
The soft fleshy cap ("fruiting body") is the part used medicinally.
What Is Shiitake Used for Today?
As yet, there are no proposed uses of shiitake mushroom or shiitake mushroom extracts that are supported by reliable scientific evidence.
Current investigation of shiitake focuses primarily on the potential immune-stimulating and anti-cancer effects of some its constituents, most prominently lentinan (LNT), a polysaccharide substance in the beta-glucan family. Limited evidence from case reports and highly preliminary human studies hints that use of intravenously injected, purified lentinan might enhance the effectiveness of chemotherapy for stomach cancer, pancreatic cancer, and ovarian cancer. 1-4Note : Do not attempt to inject lentinan products designed for oral use.
One study found hints that oral lentinan might reduce recurrence rates of genital warts following laser surgery. 11
Extremely weak evidence hints that lentinan might have immune stimulating 6-9 and liver protective effects. 10
In an animal study, lentinan reduced risk of colon cancer in mice with ulcerative colitis . 5
One study failed to find oral shiitake extract helpful for treatment of prostate cancer. 14
When taken orally, shiitake mushroom is most commonly used in the form of an extract: lentinus edodes mycelium extract (LEM). The typical dose of LEM is 1-3 grams 3 times daily.
Purified lentinan suitable for intravenous use is licensed as a pharmaceutical in Japan; it is not available in the United States.
Safety Issues
As a widely eaten food, shiitake mushroom is believed to be fairly safe. As with any food, allergic reactions can occur. 12,13
The safety of concentrated shiitake extracts, however, is less clear. Safety in pregnant or nursing women, young children, or people with severe liver or kidney disease has not been evaluated.
Revision Information
- Reviewer: EBSCO CAM Review Board
- Review Date: 12/2015 -
- Update Date: 12/15/2015 -


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Dowelltown Stump Grinding Services
Stump Grinding Service
Stump grinding is among the most over-looked portion of a homeowner's plan to get rid of trees from their property. The truth is that almost all tree service companies will not include stump eradication as part of their standard service. I have observed some companies quote a bigger amount for stump grinding than they did for cutting down the trees. Of course there's definitely some people who think that eliminating the stump is not hard, however they typically find out that's not the case.
As the name here suggests, a walk behind stump grinder is not only straightforward to walk behind and use, but it's clearly the most widespread. An easy way to define it is like a lawn mower that the individual stands behind as the grinding blades cut through the stump. High speed rotating blades make it possible for a stump grinder to pulverize a stump at the same time the operator utilizes a lever to push and pull it. Because a walk behind stump grinder is not hard to make use of and transport, it has come to be extremely popular in the rental market place. If you would like to grind up just one or two smaller stumps, a walk behind stump grinder will often be your best option.
There are various methods to select from to permanently do away with a stump in your yard. Numerous years will be called for but one approach to get rid of a stump is to pour chemicals on it that speed up decomposition. You can try digging it out yourself as long as you own a pick up truck, a few chains, and a buddy or two that are quite easily bribed with beer and pizza. I'd definitely look at using dynamite on a stump, but only if there was nothing around it and the neighbors don't think it's a big deal. Then again you could invariably simply get a stump grinder rental or hire somebody to come get rid of the stump for you.
Stump grinding to a minimum of 6 inches below grade level is a typical technique which should always be done. To ensure good results in replanting the area above the ground down stump, you are going to need at least that much room. You may want to wait around six months before planting grass though to be sure the roots don't consume all the nitrogen out of the brand new soil you put down. After grinding down the stumps, we will have lots of mulch left that you could simply use in surrounding flower beds or around other trees.
As soon as you learn how to use a stump grinder effectively in stump grinding, you'll discover that it's rather straightforward and actually pretty cool. Acquiring help from others or using the services of a tree service to grind your stumps is a wise move if you believe that you won't have the capability to handle the machine. It's extremely important to make sure you follow all safety precautions while using a stump grinder.
It is not always necessary to hire a professional for stump grinding or removal of the roots, there are several companies available on the market which provides grinders and other equipments for rentals. Before giving these grinders and tools, the safety measures has been provided by the company or the customer will have to take care of themselves. Using these kinds of power tools and equipments requires skills and knowledge. Another option is that, if homeowner do not like to choose the hiring equipment options for stump grinding, the best yet harder part would be to go manual way where he or she would need the mattock and probably it would take several hours of time or ever one or two days which depends on the size of the stump or tree. Apart from this, the homeowner or person would also require tools and equipments such as hoes, exes, picks, chain saw etc all these would help to dig up the mud or dirt and cut the roots. This manual method is very time consuming however it is cost effective. The success rate of this method is quite less since not the complete stump and root parts will be removed properly.
After having a tree professionaly taken away, your yard will still include a stump and the tree's root system in it. The removal of a leftover stump is crucial for almost all home owners although some won't mind in the least. Just have a stump extracted if you're highly anxious about your home's value or look and feel. Surely, how you remove a stump is the question that should be answered next.
There are many options available when seeking for stump grinding service. After all is said and done, grinding them down is generally the most inexpensive approach to take. It's essential to ensure that in addition to the stump, the tree's roots also are eliminated with the grinder. Leaving stumps and roots out in your yard could very well end up being quite pricey. Lots of lawn mowers have been the victim of bent crankshafts after striking an exposed stump. Stumps don't look great in a yard, and even more importantly, they can be a paradise for termites and other vermin that might make life miserable for you. Making your yard appear nice is, of course, a wonderful reason to eradicate a stump, however don't ignore that it is going to be less dangerous for everyone as well.
Without the appropriate tools and equipment, any work done will be an effort gone to waste. If the individuals were to try to remove it in person, it would end up being a disaster. The stub might have been over a connection of water in electricity pipes leading into the house. Stump Grinding comprises of a team of very friendly technicians who can understand the needs of their customers precisely and work towards giving them exactly what they need. With great skills, communication, and experience, they deliver the best service to their clients at reasonable and affordable prices.


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T-Shirts - Short & long sleeves, with Wave logo and other designs. Keep checking back for new styles! Sweat Shirts - Hoodies, joggers, crew necks. Wave Logo and other designs printed or embroidered Slipmats - Made of the highest quality felt, these are sold in pairs. Bags - Made to order from the finest materials and with our embroidered Wave logo, you won't wanna be without one!
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Monday, March 30, 2020 | 2:16 pm:In order to help protect patients, family members and health care workers from the spread of COVID-19, no visitors are allowed at any of Wake Forest Baptist Health's outpatient or inpatient facilities, except in certain situations.Learn moreAt this time, Wake Forest Baptist Health is following state and national guidelines and is limiting COVID-19 testing in the outpatient setting to only patients ill enough to require admission to the hospital.
More COVID-19 Updates
If you've ever had the flu, you know how bad it can make you feel. To help avoid all that misery — as well as possible health complications — doctors now recommend that all teens get a flu vaccine every year.
Hate getting shots? There's good news: The flu vaccine also comes in a nasal spray.
The main reason for getting vaccinated is to spare yourself the misery of flu. But there are other reasons to get vaccinated too.
It's especially important for people with certain medical conditions (like kidney disease, diabetes, HIV, heart problems, or asthma) to get a flu vaccine. They are more likely to have serious complications (like pneumonia) when they get the flu.
Kids and teens who take aspirin regularly also need to be vaccinated. They are at risk for developing a serious condition called Reye syndrome if they get the flu.
Another reason for getting vaccinated is to protect the people around you who might get seriously ill from flu — like babies, people with serious illnesses, and the elderly. When you protect yourself with a flu vaccine, you also protect other people who are more vulnerable because there's less chance you'll get the flu and pass it on. Scientists call this "herd immunity."
The best time to get a flu vaccine in the United States is before flu season starts. This gives the body a chance to build up immunity before the winter flu season. It's best to get vaccinated as soon as this year's flu vaccine becomes available in your area. (Your mom or dad should be able to find out when that is from your doctor's office, or you can ask your school nurse.)
Even if you can't get vaccinated right away, getting a flu vaccine after flu season begins will still give you some protection. You also can protect yourself against the flu (and many other infections) by washing your hands well and often.
Flu vaccines are available as a shot or nasal mist (a spray that's squirted up the nose). The shot contains killed flu viruses that won't cause people to get the flu, but will cause the body to make antibodies to fight off infection by the live flu virus.
The flu shot is very effective at protecting against the flu, but it's not 100%. A few people who get the shot will get the flu. In addition, the shot only contains certain strains of the virus. If a new flu strain emerges, a person who's had a shot may not be protected against it.
If you hate getting shots, ask your doctor about the nasal mist vaccine. The nasal mist is different from the shot because it contains weakened live flu viruses instead of killed viruses. Because it contains live viruses, the nasal mist isn't for everyone. For example, people with weakened immune systems (from certain illnesses or medications) shouldn't get the nasal mist. Check with your doctor to see if you can get the nasal mist vaccine.
It's possible to have some minor side effects for 1 or 2 days after getting a flu shot, like soreness in the area where you got the shot. Some people may feel achy or have a mild fever after getting the shot. But the side effects aren't as bad as the flu, which can make some people sick for as long as 2 or 3 weeks.
A few people who get the nasal mist vaccine can develop mild flu-like symptoms that go away after several days.
If you have an egg allergy, get your flu shot in a doctor's office, not at a supermarket, drugstore, or other venue.
Reviewed by: Elana Pearl Ben-Joseph, MD
Date reviewed: September 2015
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