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An Artistic Education
Andrea Duffie
A few years ago, while in graduate school, I was visiting with my grandmother over lunch and we ran into one of her friends at the restaurant. After introductions were made, talk turned to what I was studying (Art History) and from there, to local museums.
"You have been to the Modern Art Museum in Fort Worth, yes?" inquired my grandmother's friend, in a heavy accent that I couldn't quite place.
I assured her that I had. It was one of my personal favorite museums, and I visited every chance that I got.
"It's a fine museum," agreed my grandmother's friend. "But I regret that I cannot visit it. Because of the painting."
Confused, I asked for more details about the painting in question. After hearing her describe it further, I realized the work that my grandmother's friend was referring to was Aschenblume (1983-97), an extremely large work by German artist Anselm Kiefer. The painting usually hangs in the first of the Modern's permanent collection galleries and depicts the Chancellery of the Third Reich in Berlin. Kiefer overlaid much of the piece with a mixture of paint, cement, dirt, clay, ash, and a single large, dried sunflower.
How is it possible, I asked this woman, that this single painting could keep you from visiting an entire museum?
"I was a young girl, perhaps six or seven years old, when the bombing began in Vienna, near my home," she explained quietly. "My sister and I…it was weeks before we left Austria for America…we were in the tunnels, and we were buried for a while by the rubble. And when I saw that painting, as soon as I walked into the room, it all came back to me – the sounds, the smells, the soot and the ash in the air – and I simply could not go on."
"I cannot visit that museum again while that painting hangs in the gallery. It is just...too much."
I was speechless by the time she finished her story. At this point, I had walked by Aschenblume countless times during my many visits to the Modern. I had always been struck by its scale, and I knew the work's backstory – that this painting was one of Kiefer's attempts to come to terms with his national identity as a German in a world still reeling from the fallout of WWII. I also knew that Aschenblume, with its delicate, upside down sunflower, was also representative of transformation, of new life and new beginnings rising from the ashes.
These facts and the artist's intent were all things that I knew – I'd read about them, I'd studied them in classes. But I'd never really gotten it – never truly understood the impact, nor recognized the emotional turmoil that would have driven Kiefer to create this monumental work.
And honestly, until that moment, I don't think I'd ever really appreciated how a work of art could provoke such a visceral, overwhelmingly powerful effect on someone.
The experience of talking to my grandmother's friend that day caused a profound shift in my thinking about art. I realized that in order to truly know a work of art, to intimately appreciate it and understand it, you can't just stick to textbooks and art theory.
Art has to be connected to people, to ideas, to emotions and philosophies and culture, while leaving some room for different perspectives and interpretations made by others. Art needs to be connected to history, both past and present, so viewers can learn from it and prepare for the future. Art should be explored through questions, examining all sides of an issue – the light and the dark, the good and the bad – while often acknowledging that there may be more than one answer, and that the piece itself asks questions too.
Most importantly, this experience taught me that each of us experiences art in a way that directly reflects our own life experience...and that there is no "right" or "wrong" way of interacting with it.


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TUI Group is an international travel company based in Hanover, Germany. It's the largest tourism firm in the world.
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Bristol Mayor George Ferguson has approved a funding package for the long-awaited arena in central Bristol
Plans to build a 12,000-seat arena on the site of a former diesel depot adjacent to Temple Meads Station took a step closer last night (16 January) as the mayor approved a three year spending plan for construction.
Construction of a venue for the city was one of the former RIBA President's key election proposals and it is hoped the venue will be completed by 2017.
The approved plans will need to be rubberstamped by the full council next month.
Ferguson says 'my cabinet decision takes the project one step further with the only two remaining hurdles being the LEP Board to approve City Deal funding and the City Council budget meeting on 18th February.
'All signs are that there is cross party agreement so I hope to be able to push the button on the operator appointment, design brief and procurement stages by the end of February, to meet a planned 2017 completion.
We are planning on the architectural competition taking place later in the year.'
AECOM has been appointed as the cost consultant for the scheme.
Ferguson approves £91 million financial plan for Bristol Arena
RIBA launches £90m Bristol arena design contest
Bristol seeks architect for 1,000 new homes
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The 'last straw': Students create soybean straws as non-plastic alternative – Purdue Exponent
Ruth Zhong and Natalie Stephenson were on their way home from the library last August when they walked past a garbage can overflowing with plastic straws and cups.
At the time, the pair had been interested in entering a competition hosted by the Indiana Soybean Alliance in which students were encouraged to develop original applications for soybeans to address a market demand. It was the sight of the plastic straws that sparked the idea of developing a biodegradable soy straw.
"(Plastic waste) is a huge topic right now and plastic straws are starting to get banned in a lot of places, so we thought it was the perfect time to penetrate that market," Stephenson said.
Stephenson and Zhong, seniors in the Krannert School of Management and College of Engineering, respectively, didn't have a background in biology or food science. After contacting faculty in the food science department for guidance, the pair met graduate student Morgan Malm, who provided much of the initial knowledge the team needed about plant materials processing. The three formed Team Stroy in October and developed a disposable soy straw for the Student Soybean Product Innovation Competition in late March, winning first place and a $20,000 check.
Plastic straws are still cheaper than their eco-friendly counterparts at about 0.5 cents per unit. However, Zhong said that soy straws, which run at about 5.5 cents per unit, will likely be comparable in price to paper straws (now the leading plastic straw alternative) after mass commercialization.
Soy straws may also outperform paper straws in durability and overall quality. Although the trio is still experimenting with creating a proper "feel" for the straws, soy straws retained their form and functionality for one hour in both hot coffee and water and for five hours in soda during preliminary testing — a significant competitive advantage over paper straws. Confectioner's glaze, also used on candy, is used to coat the straws to give them a more plastic-like texture.
Team Stroy's next hurdle will be finding a way to mass manufacture their straws, which are now handmade from soy solution. They hope to eventually replace the straws used in restaurants, coffee shops and bubble tea outlets.
"We would love to start a company and commercialize this product," Zhong said.
According to Stephenson, soy straws may also be a lucrative replacement for the paper straws now used on campus.
Purdue Dining and Catering made the switch in March from plastic to paper straws across all campus residential and retail outlets. Although some students viewed the switch favorably, paper straws have drawn a number of complaints. Some paper-straw users on campus complain about the fragility and lack of structure to the straws.
"I know people who've used paper straws to drink smoothies, and they'll have to use two or three just to finish (their drink) because the straws get soggy and disintegrate," Zhong said.
Tyler Nguyen, a sophomore in the Krannert School of Management, agreed with the sentiment, saying that paper straws are not a practical plastic alternative in the long run.
"(Paper straws) suck," Nguyen said. "They break off once they get wet … and sometimes the paper gets stuck in your mouth."
According to Purdue Dining's student success manager Mary Jo Zeiser, discussions over a potential transition to more sustainable straw alternatives started nearly three years ago when the University became aware of just how much plastic waste was generated on campus. In a press release, Dining and Catering officials estimated that 650,000 plastic straws were used across dining and retail locations in 2018 alone.
Although Dining and Catering has contracted paper straw manufacturer Aardvark to supply all straws on campus into the indefinite future, Zeiser said that the Purdue would be open to exploring alternatives like soy straws.
"As long as the price point between the two is very similar and all the same qualities are present, I don't see why we wouldn't try (soy straws) at some point," Zeiser said.
Team Stroy does not yet have a concrete timeline for when their straws could enter the market, but the group plans to continue working on product development and research.
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Thursday Mornings with The Great Zucchini
Date: 9/26/2013
Time: 11:30 am to 12:30 pm
Location: Jammin Java - 227 Maple Avenue East, Vienna, VA 22180 (View Map)
Description: The Great Zucchini, Washington's funniest and most magical PRESCHOOL & KINDERGARTEN entertainer, performs a colorful magic show where every child is a star and guaranteed to laugh! Experience the excitement of the children when they get to learn a magic trick at the end of show! For over 12 years, The Great Zucchini has been entertaining young children as a magician and preschool teacher. He performs his hands-on, interactive magic shows to more that 250 groups a year. His experience, coupled with his gentle nature and wacky facial expressions, makes kids immediately feel comfortable and ready to laugh. The wonder of magic, silliness of comedy, and interactive nature of The Great Zucchini's show keeps children on the edge of their seats. Watch your kids' faces light up as they see things disappear and reappear. Watch how animated and excited the children get when they yell "Wake up Zucchini," when he accidentally falls asleep during the show or when he turns tissue paper into colorful rainbow streamers, or when his puppet, Ruffles the Rabbit, keeps coming out of the hat without The Great Zucchini noticing. This is "eye candy" magic comedy at its best. Have your cameras ready. You'll get some terrific pictures of the kids laughing the entire 40-minute show.
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Volunteers Needed - Phoenix Rising Meal Program
Date: 9/26/2013
Time: 7:00 pm to 9:00 pm
Location: Franconia United Methodist Church, 6037 Franconia Road, Alexandria, VA 22310 (View Map)
Description: Franconia United Methodist Church, 6037 Franconia Rd, Alexandria, is part of a group of churches that serves a nutritious bagged meal to homeless people living in the woods, their vehicles, and in motels along the Route One corridor between North Kings Highway and the Fairfax County Parkway in Alexandria. All ages can help prepare and assemble the bag lunches and assist in delivery. We deliver the meals the fourth Friday of the month at 5:30 pm, and we prepare the meals on the day before (Thursdays) at 6:30 pm. Contact us at 703 971-5151 or email@example.com. Website: http://www.franconiaumc.org. We're at the corner of Beulah and Franconia, next to Franconia Elementary School, on Fairfax Connector buses 231, 232, and 310. Our 2013 schedule is Jan 24 & 25, Feb 21 & 22, Mar 21 & 22, Apr 25 & 26, May 23 & 24, Jun 27 & 28, Jul 25 & 26, Aug 22 & 23, Sep 26 & 27, Oct 24 & 25, Nov 21 & 22, and Dec 26 & 27.
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Show someone special just how much you care with this romantic break. Nestled in the English village of Horningsham, the Bath Arms mixes elegant tradition with quirky touches. You'll be given truffles and a bottle of bubbly on arrival, setting a truly romantic mood, and you'll be able to sample some delicious British cuisine in the hotel's restaurant. Whether you choose to explore the surrounding Longleat estate or just relax together in your room, you'll be sure of an unforgettable stay.
Your voucher is valid for ten months for two people. The voucher may be used Sunday-Thursday only (excluding all school holidays, Bank Holiday Sundays, Christmas, New Year's Eve and Easter Holidays). This package includes one night's accommodation for two people in a luxury room, wine and truffles to share, dinner (up to the value of £25 per person) and breakfast prior to check out. All dates are subject to availability. Please mention any special dietary requirements or any special requests at the time of booking.


text: All eyes may be on the Marjah offensive in Afghanistan, where the Taliban is now using human shields according to some reports, but Iraq bears attention too: Sectarian strife and violence may be returning to the country, and this time there's not a significant U.S. troop commitment to help quell it. Last month, Sunni extremists targeted Shiites during a holy pilgrimage, and recently a Sunni man who lives in a Shiite neighborhood was murdered during a soccer match. "All we're doing is setting the clock back to 2005," a senior U.S. military official tells The Washington Post. "The militias are fully armed, and al Qaeda in Iraq is trying to move back from the west. These are the conditions now, and we're sitting back looking at PowerPoint slides and whitewashing."


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Hurricane Irene did $7 billion in damage to the eastern seaboard last month, extending from the Carolinas to upstate New York and Vermont, immediately followed by Hurricane Katia. A double-whammy of wild weather, yet welcome to surfers in the Quiksilver Pro New York competing to claim the biggest payday in the sport --- $1 million in total prizes, with Australian Owen Wright winning his first Association of Surfing Professionals victory and a check for $300,000.
Damaged property and egos exempted, surfing is serious business, with the overall industry (equipment and apparel) exceeding $6 billion annually. Sponsorships for free boards and wetsuits are assumed, yet the Dominican Republic, Vans footwear, New Era caps, Pabst Blue Ribbon beer, and recent market entry Nike underscore the diversity and profit potential of catering to the surfing lifestyle.
Exhibit A: The New York Surf Film Festival (www.nysurffilm.com). Attendees overflowed from Cinema Village on East 12th Street and the restaurant next door, Stand 4, which was reserved for sponsors, filmmakers, fans and cinephiles to grab a drink and Kobe burger between 40-some feature and short-film screenings. Sharing what trip afar or film project is next, attendees were given product demonstrations, gratis samples (whether a taste of Brugal Rum or Goose Island beer) and treated as if on the red carpet at the Kodak Theater, Hollywood, instead of just off sandy Long Beach and now in Greenwich Village, NYC.
"The film festival was a great opportunity, it's an awesome, organic thing." lauds Josh Berg, NYC Brand Ambassador for SkullCandy (www.skullcandy.com), a headphone manufacturer and sponsor of the New York Surf Film Festival, "It's more than a sport but a lifestyle, a movement."
To call surfing an industry is indeed an anomaly, and somewhat offensive to those who live to surf. Lifestyle, community, or even addiction, seems more appropriate. Ever scanning weather reports for big waves, surfers are also famously loyal, whether to their significant other or one another, especially when in the water. New entries, whether a surfer or company, are viewed with suspicion until they prove themselves.
"It's harsh to say but our industry is not really open to outsiders, with players like Quiksilver, Billabong and O'Neill involved and investing for many years." details Tony Perez, publisher of Surfer, Surfing, and SUP magazines, to name a few action-sport titles at GrindMedia (www.grindmedia.com). "When outsiders come in, the community wants them to really give back. You can't fake it, you have to be authentic, because the kids will figure it out."
In a sport where fistfights for stealing a wave are common, the co-founders of the New York Surf Film Festival are now finishing one of their own – not in the water but court.
"I met Tyler surfing." offers Morgan Rae Berk of fellow (and now former) New York Surf Film Festival co-founder Tyler Breuer, and how the festival was first envisioned, "We were talking about how we always wanted surf movies to be in a theater, then looked at the numbers and realized that a single-showing could never happen. Ticket sales alone wouldn't cover the expense of staging screenings, so that's when the idea of teaming them all together into a single festival made sense."
Following more than a year in litigation, the former partners can now only seem to agree that they met in the Atlantic. "The idea for the festival was Tyler's idea in 2003, he conceived it long before he even met Morgan…" counters Andrew Heyman, a medical device litigator based in New Jersey and an old friend of the festival's former-co-founders, Tyler, Adam Cannizzaro and Michael Machemer. Andrew has been consulting the three in the final months of the case, adding, "[Morgan] wound up with all of it. It really is an unfortunate end."
Rewind four years, a growing industry needing an outlet, and four 20-something partners seeing nothing but promise. JetBlue sponsoring the first New York Surf Film Festival gave the annual event credibility, and it has grown year-to-year. Tyler manages his family's Sundown Ski and Surf Shop in Levittown, and Morgan is an event marketing expert based in Brooklyn, focused on social media and digital distribution, consulting Mashable, Vimeo, and other technology firms, manufacturers and the tourism sector. "Four people living in four different places and never able to meet, with full-time jobs. The respective level of commitment for the partners became very obvious." affords Morgan of how the partnership began to fray.
Andrew, on behalf of his friends, isn't so diplomatic: "Morgan is a Johnny-come-lately."
Who's doing more work is always in question in companies, especially small partnerships, but even Andrew concedes that it was Morgan who asked for specific job descriptions and responsibilities for the four respective partners. And her claims that her former-partners were unresponsive, with the brunt of the festival's many calls and strategy falling on her shoulders – ultimately forcing a legal split – seemed confirmed. Multiple calls and emails to Tyler for this article went unanswered; the voicemail to his endeavor "SMASH" even mentioned the New York Surf Film Festival (despite Morgan recently winning all rights to the festival's name, trademark, logo et al).
Enter Andrew at deadline, explaining, "I represented these guys pro bono but, by the time I got into it, they had used all of their money fighting the lawsuit. These guys have known each other 10 years or more, and it was starting to fray even their friendships." Pointing to how loosely the four formed the LLC "Don't Drop In" initially, overlooking several operating guidelines that would soon become critical – including voting rules requiring "over 75% agreement among partners" (which is impossible between four people with one disputing any matter, ownership especially) – Andrew offers, "I wish I was representing them from the start."
A graduate of Cornell University's School of Hotel Administration, Morgan has handled big events before, but the film festival in 2010 was easily most abrasive. According to court records, just prior to the festival, the three other partners had essentially voted Morgan out of Don't Drop In. She didn't learn this from them, though, but from their screening venue. "I got a call one day from Tribeca Cinemas telling me that I wasn't a partner anymore. That's when I learned that my partners had hired a lawyer. I sued them because they were claiming to take away my 25% share in the company, an LLC."
Andrew's narrative instead focuses on the intellectual property the four created together. "What happened was, they discovered after the 2009 festival, that she [Morgan] had registered the trademark and logo in her own name. They discovered this as the relationship was faltering. But that was the one thing that really sent them around the bend. They said the LLC must have ownership of the logo and mark. She said no, I'll license it to you, but no. I own it."
Morgan doesn't dispute the fact that she registered the web site URL www.nysurffilm.com under her own name, but before the LLC was formed, and that she offered to transfer it into the company in return for fixing the faulty operating agreement. Curiously, Andrew also states that Morgan "had nothing to do with the planning or promoting of the 2010 festival," with Morgan laughing in response, "I was there, every three days. I'm not surprised that my former-partners don't understand that it's a 365-day cycle to pull-off an event of this magnitude."
He said, she said.
And, as Morgan did the planning and promotion for the 2011 festival, her former partners used an alias web site to broadcast their views on the lawsuit, disparaging her legal case and confusing the surfing and filmmaking community. Andrew defends his friends using this site, adding via email that, "one of the reasons they activated that site was because [Morgan] blocked their access to the official festival website." Either way, anyone searching for the festival found two different stories online, with concerns arising if there would be any New York Surf Film Festival in 2011 at all.
The way some surfers may act in the water is no way to act in business.
"There was a moment when I thought about quitting because it was such a giant hill to climb to get my name back in the community." admits Morgan, "Then filmmakers, the surfing community, and sponsors said to me, 'Don't you dare quit, this is what you built.'"
The lawsuit was settled in Federal trademark court last month – An ugly end for four friends who created a festival to celebrate their sport.
"We've been supporting the New York Surf Film Festival since its inception, and when I heard what was going on – and I got calls from both sides – I told them to work it out because what they've created was so special and that we're going to support whoever gets this." recalls Tony Perez at GrindMedia. "What Morgan did was help some of the non-endemic partners get involved, opening doors, and doing more than building a great film festival."
An agreement now signed and the lawsuit officially dismissed, all parties can now look to the future. No party is restricted from promoting surfing events in the final settlement. Tyler Breuer and the other former-founders of the New York Surf Film Festival have launched "SMASH" (Surf Movies Art Shaping History) with the mission (according to their web site www.smashsurf.com) "to present, in a public forum, a body of emerging and historical work from the local and global surf community throughout the year." including lectures with the stars of surfing and workshops.
And Morgan has her fourth New York Surf Film Festival under her belt, her first alone with rave reviews and sponsors and filmmakers eager to sign-up for next year. Smiling in reflection, Morgan can finally say, "Now I'm on my own."
The next obvious step for the festival is going international, and digital, shares Morgan, "I get a lot of people from Europe and South America wondering how to do this, so we're starting to consider a single submission venue, while also creating a fund for filmmakers to produce great films. Broader distribution monetization strategies to create residual revenues for content creators are key. Without high qualify films, I can hardly hold a high quality film festival."
Despite the tumult, the industry lauds that the annual festival is continuing, and growing.
Doug Walker, whose film "Lost & Found" premiered at the 2011 New York Surf Film Festival, could only offer praise for both the exposure and audience. "This being my first surf film festival, it was nice to see how it catered to finding films that made art appeal to viewers beyond surfers. Yes, my film is a surfing film, but now that it's being seen by others, it's touching outsiders beyond the surfing community, and that's really amazing."


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The Camelback Fellowship
2015 Camelback Fellow Jonathan Johnson on the first day of his school, Rooted.
Camelback Ventures began with Education as its first track (you could also call it portfolio, impact area, pillar, focus — all those good words) with a pilot run out of founder Aaron T. Walker's Brooklyn living room in 2014. Today, Camelback has supported 35+ education entrepreneurs, leaders of innovative school models, creators of thoughtful programming, and game-changing technology. We began with education because we believe it is at the core of our mission and vision to create a nation of livable communities where everyone has the opportunity for a quality education and a good life.
The Camelback Fellowship is a rigorous accelerator for underrepresented entrepreneurs; we provide coaching, capital (up to $40,000), connections, community, and curriculum. Our Education track for 2020 will feature all of the lessons and expertise we've developed over the past years along with new learnings and projects. We have a secondary sub-track for Schools — every school that has gone through Camelback Ventures has gone on to receive prestigious New Schools Venture Fund recognition and support. Popular features of the Education track include learning how to evolve from being an educator to an entrepreneur, how to build business plans and secure funding, and becoming the best leader one can be.
Meet a few of our Camelback Fellows in Education
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In the Map step, input documents are transformed, or mapped, from
their original structure into a new key/value pair. For example, if your
input document represents a book and contains information about the book's
ISBN (the
_id field in the following
document), title, subtitle, authors, publisher, date released, and number
of pages, then you may choose to map just the title. The result of this
mapping for a single document would be the book's title. We'll use the
following document representing a book in the examples in this
{ "_id":"978-0-596-15589-6", "title":"CouchDB: The Definitive Guide", "subtitle":"Time to Relax", "authors":[ "J. Chris Anderson", "Jan Lehnardt", "Noah Slater" ], "publisher":"O'Reilly Media", "released":"2010-01-19", "pages":272 }
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books database now. Using Futon:
Navigate to http://localhost:5984/_utils/
using your web browser and click on the
books database that you created
From the "View" drop-down menu, select "All documents" if it is not already selected.
Click "New Document".
Click on the "Fields" tab if it is not already active.
as the value of the
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At the end of 2010, Albanian banks had invested abroad funds of 1.2 billion dollars.
Compared to one year ago, the money that banks have transferred abroad was increased, according to official data, with 46.1%. For many years, a great part of the loans in foreign currency lent to businesses and individuals have been financed by loans that the banks have taken from their "mother" banks abroad.
But since September 2009, the money transfer has changed direction. The latest Financial Stability Report of the Albanian Bank says that the Albanian banking sector has turned into net lender. This means that Albanian Banks are transferring funds abroad, in the form of deposits to their "mother" banks, or in the form of loans that they give to foreigners.
The strong increase of the money that banks are transferring abroad has to do, according to the experts, with the fact that banks perceive an increased danger in the inner market and prefer to invest their money abroad, where they feel safer. But how much is this transferred amount? According to official data, 1.2 billion USD that our banks have invested outside Albania is equal to 25% of all the loans that the banks have given to the Albanian businesses and individuals.
According to the same data, only during 2010, the funds that the banks transferred abroad were equal to the money lent inside the country. Even if banks would have the financial sources to help our economy growth by loans, the foreign investments limit these possibilities. These data indicate that the decrease of bank loan levels in the country started exactly in the middle of 2009, when banks started to transfer funds abroad. Since then, the credit increase, contrary to what the Albanian Bank had predicted, keeps staying at even lower levels, although the financial crisis has passed and the demand has increased.
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1960 Fulton Street
San Francisco, CA 94117 / Lone Mountain, SF District 1, SAN FRANCISCO COUNTY
1960 Fulton Street is a well maintained 8 unit apartment building with 3 car parking located in the Lone-Mountain/ USF location of San Francisco. The unit mix consists of 4 studios and 4 one-bedroom units. 400k of recent capital improvements including the mandatory soft story retrofit work. Tenants pay their own separate utilities and 7 out of 8 tenants pay their proportionate share of the the building utilities.
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Dimitris Drolapas
The data relating to real estate for sale on this web site comes in part from the Internet Data Exchange (IDX) of the San Francisco Association of REALTORS Multiple Listing Service. Real estate listings held by brokerage firms other than Vanguard Properties, Inc. are marked with the IDX logo and detailed information about them includes the name of the listing brokers. The information being provided is for consumers' personal, non-commercial use and may not be used for any purpose other than to identify prospective properties consumers may be interested in purchasing.
Information has not been verified, is not guaranteed, and is subject to change. Last Updated: 10/18/2019


text:
Reasons for Telephone and Unscheduled Consultation in Patients Undergoing Hepatitis C Treatment
Marta Gallach1*, Maria López2,3, Meritxell Casas4, Mireia Miquel2,4, Angelina Dosal3, Laura Moreno3, Jordi Sánchez Delgado2,4, Blai Dalmau4, Xavier Calvet2,4 and Mercedes Vergara2,4
1Emergency Department, Hospital de Sabadell, Spain
2Universitat Autònoma de Barcelona, Spain
3Nursing, Hospital de Sabadell, Spain
4Hepatology Unit, Hospital de Sabadell, Spain
Submission: July 26, 2016; Published: August 05, 2016
*Corresponding author: Marta Gallach, Emergency Department, Hospital de Sabadell, Parc Taulí, 1, 08208 Sabadell, Spain.
How to cite this article: Marta G, Maria L, Meritxell C, Mireia M, Angelina D,et al. Reasons for Telephone and Unscheduled Consultation in Patients Undergoing Hepatitis C Treatment. Adv Res Gastroentero Hepatol. 2016; 1(5): 555574. DOI: 10.19080/ARGH.2016.01.555574
Adherence to treatment is a key to improve cure rates in patients with chronic hepatitis C on interferon-based therapies. We aimed to determine the main reasons for telephone consultations and unscheduled visits in hepatitis C patients under antiviral treatment.
Methods: We included all patients with hepatitis C treated with pegylated interferon plus ribavirin who consulted our department by telephone or unscheduled visits.
Results: A total of 176 patients (mean age, 48 years; 67.6% male) were under treatment in the inclusion period. We registered 264 phone consultations and 193 unscheduled visits by 109 patients (53% women). The most common reason for telephone consultation was adverse effects (40.2%). The most common actions in response to telephone consultation were providing information (58.3%) and ARGHanging or advancing appointments (22%). Reasons for unscheduled visits included adverse effects (59.1%), errors or administrative queries (13.4%), questions or doubts related to treatment (10.4%), and problems with medication devices (7.7%). Actions in response to unscheduled visits included medical visits (33.7%), training by nurses (24.9%), referral to other specialties (10%), laboratory tests (8.8%), prescription of medication (7.8%), administrative procedures (6.8%), discontinuation of treatment (2.6%), and transfusion (2.1%).
Conclusion: Most telephone consultations or unscheduled visits of patients on chronic hepatitis C treatment are related to adverse events.
Keywords: Hepatitis C; Adherence to medication; Nursing care; Multidisciplinary team; Interferon; Ribavirin
Abbreviations: HCV: Hepatitis C Virus; CHC: Chronic Hepatitis C; Peg interferon: Pegylated Interferon; SVR: Sustained Viral Response; HCV RNA: Viral Load
It is estimated that 1.6% to 2.6% of the population in Spain is infected with the hepatitis C virus (HCV) [1]. About 80% of infected people will develop chronic hepatitis (CHC), and 20% of these will eventually develop cirrhosis, and 5% to 10% of patients with cirrhosis due to HCV will develop hepatocellular carcinoma [2]. CHC is the most common cause of cirrhosis and liver transplantation, not only in Spain, but throughout developed countries [3-5].
Until 2011, the treatment of hepatitis C was based primarily on the use of pegylated interferon (peg interferon) alpha-2a or alpha-2b plus ribavirin for 24 to 72 weeks depending on viral genotype and viral kinetics during treatment [6]. The infection is considered cured when the patient shows a sustained viral response (SVR), defined as undetectable viral load (HCV RNA) 12 weeks after the end of treatment. In patients with an SVR, laboratory test results return to normal, liver disease stops progressing, and histological examination can even show regression of liver damage [7]. Newly developed direct antiviral agents will dramatically increase the rate of SVR in patients with chronic hepatitis C; however, direct antiviral agents are currently considered too expensive in many countries, including Spain. Thus, it will probably continue to be necessary to use peg interferon alpha-2a or alpha-2b in certain groups of patients [4, 8-10].
Interferon-based antiviral treatment is associated with a high rate of severe adverse events, so it requires close monitoring. Moreover, peg interferon must be administered subcutaneously, so it requires frequent visits to the hospital [5-11]. However, many adverse events are easily controlled [12]. The accurate and intensive management of adverse events improves adherence, and consequently increases the SVR rate [13]. Some studies have shown that some specific interventions in the setting of a multidisciplinary team (psychiatrist, pharmacist or a dermatologist) to improve the management of adverse effects can increase adherence and effectiveness [4,14,15]. Communication with the rest of the healthcare team and monitoring patients by telephone is important [16]. We hypothesized that most doubts related to hepatitis C treatment could be resolved by telephone. The aim of our study was to determine the reasons for telephone and emergency consultations of patients treated with interferonbased therapies for chronic C hepatitis in the setting of a multidisciplinary team and the extent to which telephone consultations resolved patients' doubts without the need for scheduled visits.
Material and Methods
This was a prospective observational study of clinical practice in the setting of our multidisciplinary team to manage patients undergoing treatment for CHC. Our institution's clinical research ethics committee reviewed and approved the study, and all patients provided written informed consent. On starting antiviral treatment, all patients had an initial educational visit with a nurse, who instructed them in the subcutaneous administration of peg interferon and informed them about self-care for adverse events. Moreover, patients received educational materials including a telephone number to contact during working days and the timetable for care in outpatient clinics. We registered all telephone consultations and unscheduled visits by patients under antiviral treatment with peg interferon and ribavirin that took place from January 2009 to January 2011.
Variables Recorded
- Demographical variables: age and sex.
- Type of consultation: by telephone or by presenting at the outpatient consultation in person.
- Date of consultation, type of treatment, and treatment week.
- Reason for consultation (administration, medication storage, adverse effects, adherence, and other doubts).
- Results of the consultation.
Statistical Analysis
Quantitative variables are presented as means and standard deviations and qualitative variables as frequencies or percentages with their 95% confidence intervals. We used SPSS v21 (IBM, Chicago Illinois, USA) for all analyses.
Characteristics of the patients
Between January 2009 and January 2011, a total of 160 patients (108 (67.6%) men; mean age, 48±11.7 y) received antiviral treatment in our unit. HCV infection was classified as genotype 1 in 112 (69.9%) patients, genotype 2 in 9 (5.7%), genotype 3 in 22 (13.6%), and genotype 4 in 17 (10.8%). Peg interferon was injected with a syringe in 60.3% of cases (peg interferon alpha-2a) and using a pen system in 39.7% (peg interferon alpha-2b). The rate of patients that abandoned treatment was 3.5%.
Telephone consultations and unscheduled visits
We received 264 telephone consultations from 109 patients (median calls per patient, 2; range, 0-14). Callers were women in 59% of cases. Patients themselves called in 53% of cases, and family members (partner, child, and sibling) called for patients in 47% of cases.
Telephone consultations were most common during the first 12 weeks of treatment (57.2%). The main reasons for telephone consultation included: adverse effects (40.2%); doubts about hygiene, diet, or self-care (28%); administrative errors or doubts (21.2%); problems related to medication (e.g., missing a treatment dose or concomitant treatments) (8.8%); and reporting on the result of a previous consultation (1.8%) (Figure 1). Telephone consultation alone resolved patients' problems in 58.3% of cases, whereas it was necessary to schedule an urgent appointment or advance a previously scheduled appointment in 22% of cases (Figure 2). In 41 (15.5%) telephone consultations, patients were advised to come to the emergency department.
A total of 193 unscheduled visits were recorded. Unscheduled visits were recorded throughout treatment, but mainly occurred in the first 12 weeks (44.6%). Women accounted for 53% of unscheduled visits. The main reasons for unscheduled visits were adverse effects (64.7%), mainly dermatological problems (19.2%) and asthenia with or without anemia (17.6%) (Figure 3). These unscheduled visits resulted in medical visits (33.7%), education by nurses (reviewing recommendations) (24.9%), referral to other specialists (13.4%), laboratory tests (8.8%), prescription of medication (7.8%), administrative changes (6.8%), treatment discontinuation (2.6%), or transfusion (2.1%) (Figure 4).
Most of the telephone consultations and unscheduled visits in patients undergoing antiviral treatment for hepatitis C were due to adverse events secondary to treatment. However, most of these problems could be solved by providing advice on the telephone or during the unscheduled visit without requiring a visit with a physician. These results show the utility of nurses help patients improve their selfcare. A previous study in Spain pointed out the usefulness of telephone communication with patients with chronic disease and their relatives [17]. Our results confirm that a direct telephone line improved follow-up in patients undergoing interferon-based treatment. The main reason for telephone and unscheduled consultations or emergency visits was adverse effects. It is important to control adverse effects because severe adverse effects can decrease adherence to the treatment and/or require decreased dosage of antiviral, both of which decrease the chances of obtaining an SVR [11]. Similarly, adherence improves when adverse effects are well controlled [4,5].
Interestingly, although over two-thirds of our patients were men, 59% of the callers in telephone consultations were women. Other studies have reported similar results, probably because women more frequently act as caregivers [18].
Analyzing the reasons for unscheduled consultations has helped us identify gaps in our educational program. Our results show that we need to pay more attention to adverse events in the educational program and to improve patients' knowledge for self-care. Better patient education could reduce the need for consultation and improve adherence and quality of life during treatment. Hopwood et al. [19] used structured interviews to analyze factors that could improve treatment. These authors found that identifying the patient's strengths in an interview before the beginning of treatment can help clinicians manage hepatitis C treatment regimens. Wartelle Bladou et al. [20] found that preparing the treatment with the patient and employing a multidisciplinary team promote adhesion to treatment. Some authors emphasize the importance of assessing patient expectations with regard to adverse effects, as many patients are unrealistically optimistic before starting treatment [21].
The rate of treatment discontinuation due to intolerance range between 7,9%-18% [2,22]. Previous results published by our group in clinical practice showed a drop-out of 11% [5], lower than others published elsewhere. We hypothesize that easy access to the multidisciplinary team by telephone or outpatient clinics probably contributed to this low rate. The limitations of our study include the potential loss of information during telephone consultations. To minimize this point, we assigned specific members of the multidisciplinary team to handle telephone consultations and developed a standardized questionnaire to avoid loss of information. Our day hospital was only open from 7 a.m. to 17 p.m., Monday through Friday. Patients attended at the emergency department outside this timetable did not necessarily contact the day hospital if their problem was solved; thus, we cannot know the possible impact of telephone inquires or unscheduled visits outside this timetable. We found that most consultations of patients on interferon-based treatment for CHC were due to adverse effects, and that providing patients with the opportunity to consult with professionals by telephone facilitated contact. The multidisciplinary team will incorporate the lessons learned from this study to improve the self-care educational program.
Special thanks to all staff members who answer the phone and deal with emergency visits.
- Bruguera M, Forns X (2006) Hepatitis C in Spain. Med Clin (Barc) 127(3): 113-117.
- Rogers G, Campbell L (2003) Hepatitis C virus: its prevalence, implications and management. Nursing Times 99(50): 30-31.
- Dienstag JL, McHutchison JG (2006) American Gastroenterological Association technical review on the management of hepatitis C. Gastroenterology 130(1): 231-264.
- CARGHion JA, Gonzalez Colominas E, Garcia Retortillo M, Cañete N, Cirera I, et al. (2013) A multidisciplinary support programme increases the efficiency of pegylated interferon alfa-2a and ribavirin in hepatitis C. J Hepatol 59(5): 926-933.
- Vergara M, Gallach M, Dalmau B, Gil M, Miquel M, et al. (2008) Results of pegylated interferon and ribavirin for the treatment of chronic hepatitis C in clinical practice: a 5-year experience. Gastroenterol Hepatol 31(5): 274-279.
- Strader DB, Wright T, Thomas DL, Seeff LDB (2009) Diagnosis, management, and treatment of hepatitis C. Hepatology 49(4): 1335-1374.
- IñARGHairaegui M, Elizalde I, Martínez Echeverría A, Zozaya JM, Beloqui R, et al. (2004) Treatment of chronic hepatitis C virus infection. An Sist Sanit Navar 27 Suppl 2: 69-80.
- Thompson AJ, McHutchison JG (2012) Will IL28B polymorphism remain relevant in the era of direct-acting antiviral agents for hepatitis C virus? Hepatology 56(1): 373-381.
- Chopra A, Klein PL, Drinnan T, Lee SS (2013) How to optimize HCV therapy in genotype 1 patients: management of side-effects. Liver Int 33(Suppl 1): 30-34.
- http://www. redaccionmedica.com/contenido/images/ PROTOprotocolo_sofos.pdf.
- Manns MP, Wedemeyer H, Cornberg M (2006) Treating viral hepatitis C: efficacy, side effects, and complications Gut 55(9): 1350-1359.
- Gervais A, Boyer N, Marcellin P (2001) Tolerability of treatments for viral hepatitis. Drug Saf 24(5): 375-384.
- McHutchison JG, Manns M, Patel K, Poynard D, Lindsay KL, et al. (2002) Adherence to combination therapy enhances sustained response in genotype-1-infected patients with chronic hepatitis C. Gastroenterology 123(4): 1061-1069.
- Le Lan C, Guillygomarc'h A, Danielou H, Le Dréau G, Lainé F, et al. (2012) A multi-disciplinary approach to treating hepatitis C with interferon and ribavirin in alcohol-dependent patients with ongoing abuse. J Hepatol 56(2): 334-340.
- De Montjoye BB, Ferrand I, Sogni P, Podevin P (2006) Management of psychological disorders in patients with chronic hepatitis C. Encephale 32(2 Pt 1): 198-203.
- Poll R (2009) The role of the community nurse in hepatitis C diagnosis and treatment. Br J Community Nurs 14(7): 292, 294-296.
- Gisbert Ortiz M, Baydal Cardona R, Lopez Benito I (2002) Nursing and telephone technology for the care of chronic patients. Rev Enferm 25(1): 38-39.
- Leppanen V (2010) Power in telephone-advice nursing. Nurs Inq 17(1): 15-26.
- Hopwood M, Treloar C (2007) Pretreatment preparation and management of interferon-based therapy for hepatitis C virus infection. J Adv Nurs 59(3): 248-254.


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California Chardonnay Wine Kit (Winexpert Selection)
The combination of these two varieties gives a depth of complexity and character.
These kits come with everything you'll need to make a great wine, including the yeast, preservatives, clarifiers, and if called for, oak.
This Chardonnay wine concentrate kit makes 6 gallons (~30 750mL bottles) of delicious wine. And while the Selection series kits are little more expensive than the Vintner's Reserve series, we feel that you can taste that difference in the finished wine.
Note: We rotate our stock of the Selection, World Vineyard, and Eclipse kits. We may not have all kits displayed here in stock at all times, but can get any of them. If a kit is not in stock, please allow for an extra week or so for delivery.


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Burke Chiropractic is the premier chiropractor in the Minnesota Metro area. Our office is located at 7250 France Avenue in Edina, Minnesota. Apart from being a trauma specialist relating to joint pain we also work with a variety of attorneys and clinics so you are in good hands throughout your entire accident experience.
Dr. Adam Burke is the founder and one of the local doctors of 233 PAIN.
After starting college at the age of sixteen, in North Dakota, Dr. Burke moved to the Twin Cities to finish his Bachelor degree in human biology. At the age of only nineteen he began working on his Doctorate of Chriropractic from Northwestern Health Sciences University where he graduated in 2006. Dr. Burke treated many professional athletes, working with the official Vikings clinic and Twin cities marathon clinic, before establishing Edina Chiropractic Center. Additionally, he was also a lead doctor in the National Health and Wellness Bureau, as well as guest lecturer to hundreds of other doctors around the world and is known as one of the "Go To" Spine and Joint doctors in the Twin Cites. Dr. Burke has also worked with some of the local grade schools helping academically challenged grade-schoolers get back on track.
Dr. Burke's expertise includes: Back pain, Neck Pain, Auto Accident (Whiplash Injuries), Shoulder, Elbow, Wrist, Hip, Knee, Ankle, Sports Injuries, and Disc Herniations. He is proficient in Activator and Diversified Techniques, and his clinic offers only the finest state of the art equipment to help get you better, quicker.
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"Global Cleveland is Excited About 2019"
Every "first of" in a New Year gives all of us a chance to re-energize and dedicate ourselves anew to our passions and vocations. At Global Cleveland we are excited at what 2019 is already bringing. The amount of collaboration between local/county/state government and organizations like ours engaged in welcoming newcomers is at an all … Continued Read More
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There are many ways you can get connected with Global Cleveland – from networking with civic and business leaders to volunteering at a naturalization ceremony. Sign up today! Naturalization Ceremonies Help support and welcome our newest American citizens on what is of the most important days of their lives. Interested? Email firstname.lastname@example.com Community Navigators … Continued Read More
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As we walk into 2019, there is a serious discussion among employers, lawyers and international employees about filing H-1B Visa for 2019. H1B visa is a valid three years' work visa that can be renewed for another three years. Among all the industries, tech firms have been using H-1B visas to hire international talents that … Continued Read More
Global Cleveland's Own, Elizabeth Goes to the Mexican Border to Help!
Who chooses to spend a week at a federal detention center run by a private prison company on the border with one of Mexico's most dangerous cities? I do, and that's what I did in Laredo, Texas last week through a partnership Global Cleveland has with Jones Day through our work with the National Project … Continued Read More
"There Is Always Something For Which To Be Thankful"
This Thanksgiving, I am extremely thankful for our community. I am thankful for the people who make our lives better, more fulfilled, and more worth living: our international newcomers. I am also thankful for being a part of an organization like Global Cleveland that's committed to serving and supporting all those that come to Cleveland … Continued Read More
Meet Zhenting: From China to Cleveland, From Intern to Vice President
As a native of China, Zhenting brings the first-hand experience in American immigration. Zhenting began as an intern at Cleveland International Fund (CiF), then rose steadily up the ranks to Market Analyst, Operations Manager and now serves as Vice President. CiF is a proven EB-5 Regional Center that connects foreign investors seeking U.S. residency ("green … Continued Read More
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Greater Clevelanders are invited to the 9th Annual International Cleveland EXPO on Friday, December 7th – described by past participants as the "best" celebration of the area's diversity. This year the EXPO is hosted by La Villa Conference and Banquet Center at 11500 Brookpark Road in Cleveland. The parking is FREE and plentiful. The event … Continued Read More
Guest Blog: How Studying Abroad Changed My Life!
To expand my perspective and learn from experience and to take a fun break from school, I took the advantage of the opportunity to study abroad twice during my time as an undergraduate at Ohio University. My sophomore year, I participated in a Global Public Health Program in Costa Rica and my senior year I … Continued Read More
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Members of Design for America have found plenty to improve upon in and around University Circle. They helped the Ronald McDonald House organize its donations using spreadsheets, streamlined the recycling process at a campus café, and developed a pedometer that encourages the elderly to use their walkers. But as the local studio begins its sixth … Continued Read More
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On September 8, 2018 Global Cleveland held the 2nd Annual InterCLE event, a grand welcome for international students and young professionals in the region. All in attendance had the opportunity to engage with community organizations and to network with fellow international students. This event was sponsored by WKYC Channel 3, Margaret W. Wong & Associates, Case … Continued Read More