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Building Stronger Leaders
We have developed powerful and outcome based coaching programs, both individual and group settings to sharpen your leadership style and effectiveness.
Coaching facilitates deeper clarity, perspective,focus and direction. We provide a structure environment to achieve your identified focus areas. Coaching is a supportive but challenging process that produces significant,sustainable change in leadership habits, beliefs and behaviours.
Leadership can feel lonely. Executive coaching is a great resource for those at the top. Through an ongoing relationship, we can help you see the obstacles that may be holding you back from unleashing your full potential. Our goal is to support and challenge people to grow into confident and capable leaders, enhancing existing leadership styles by leveraging off an individual's strengths, increasing emotional intelligence and working through pressure points.
Sue Montgomery is the Principal of Coaching Professionals, established in 2010 Sue has experienced continued growth over this time, expanding her team of coaches now based in Sydney, Adelaide and Auckland.We enjoy long-term relationships with local and state government, engineering and construction consultancy firms and financial institutions.
Sue is currently applying for accreditation with the International Coaching Federation as a Professional Certified Coach and is a qualified team coach and highly experienced coach trainer and facilitator. Sue is an active member of the coaching community and a continual learner of her craft.
Sue is also part of the Coaching Australia team of coach trainers delivering their Executive Coach Certification Program internationally to multinational companies such as AIA, IBM, Microsoft, Coke Cola and Logitech.
In 2015 Sue was invited to participate in a global PhD study conducted through the University of Newcastle on "The effects coaching has on leaders". Two of her major clients took part in this research sending through 100 leaders to be surveyed, measuring the outcomes that coaching achieved exceeding the expectations of the University.
Sue offers clients real-world experience with over 25 years in the corporate arena. She held management roles in the banking and telecommunication sector before becoming a professional leadership coach.
Her philosophy is to partner with leaders to work through issues by providing ongoing support and facilitating the decision-making process. Her guidance allows leaders to discover their core values and work to their strengths to achieve success. She brings humility, integrity, professionalism, high-quality coaching skills and energy to her coaching..
Carli holds a Bachelor of Psychology (Honours) from the University of Newcastle. Specialising in the field of Health Psychology, focusing on the connection between mental & physical health.
Carli is also a qualified professional coach, having trained with Coach Global, who are aligned with the International Coaching Federation (ICF).
Carli focuses on combining the power of coaching with her psychology background empowering people to achieve significant growth from the coaching outcomes. If mental health issues, anxiety, self- doubt, depression get in the way of courageous and confident leadership, Carli will partner with you to move forward. Believing that mental & physical health cannot be separated, so we must treat them as one.
'I don't even talk about it (depression) as a psychiatric condition anymore...it does involve psychology, but it also involves equal parts biology & physical health.' -George Slavich
Belinda is a talented coach – lifting not only business leaders but athletes as well. Both require a high level of focus, goal setting, confidence and resilience to achieve peak performance and results. She understands the desire to want to be better and the feeling of not knowing how to make it happen. Her philosophy is to facilitate creativity, clarity, and develop a recipe for her client's success personally and professionally.
Belinda has walked the walk. As a two-time competitor in the Commonwealth Fly Fishing Champs held in England, she knows what stress feels like as a member of a team representing her country. She understands that the mind and body can fight against each other and start to shut down.
Her training with the NeuroLeadership Institute provides a scientific approach to her coaching techniques. Recent research in neuroscience is uncovering the way leaders perform and use data – to create positive change and improve effective leadership.
Belinda has a Bachelor of Arts in Psychology from the University of Canterbury - Christchurch, New Zealand. She is also an Associate Certified Coach and a SEI 1-1 EQ Assessor. As if that wasn't enough, Belinda is a certified as a Team Coach by Coach MBA-MAP.
Her passion for helping others excel has pushed her to further her expertise at the NeuroLeadership Institute in Sydney. There she achieved advanced training in 'Brain-Based Coaching' and 'Results Coaching Systems'.
Tracey is an ICF trained coach completing her Executive Coaching Certification Program through Coaching Australia. Tracey is currently working with leaders of organisations bringing her natural coaching approach, training and 18 years' experience with NSW Fire & Rescue, holding the highest rank held by a female in Fire & Rescue NSW, along with only 2 other women.
As part of her leadership role, Tracey is responsible for developing, mentoring and coaching colleagues within her organisation, and has now expanded to operating as an external coach through Coaching Professionals. She is passionate about her work and the contributions she makes as a coach and trainer to individuals and their teams.
Tracey's sporting background includes representing Australia at 2 World Championships in triathlon. Her success both professionally and as an athlete has created her vision to empower and inspire others by assisting them through a coaching partnership. The aim, to improve their thinking for optimal outcomes in their work performance, interpersonal relationships and their goal achievements.
Contact us to learn how coaching can help you become a better leader.


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100% Authentic Vivienne Westwood Sale.Free Shipping & Retun
Product 36/105
Crafted from exquisite orange peel textured leather, the Derby Bag returns for Spring/Summer 2017 in a new asymmetric shape with a detachable strap. Patterned in the iconic New Exhibition tartan, this feminine bag is finished with gold-toned hardware and the Orb emblem delicately studded to the front.
Please note that due to the cut of the fabric the tartan design will vary from bag to bag. Should you require any assistance with this please do not hesitate to contact our Customer Service Team.
Gold-toned hardwareScribbled Orb printed liningMagnetic press stud fasteningInternal zip closureOne internal zip pocketClutch strap to the backDetachable shoulder strap measures 155cm

subset: commoncrawl


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The object of the protecting shield is to enable the lamp to be used in the most violent current or fire damp without there being the least risk of the gauze getting so heated as to ignite any fire damp which may come in contact with same.
1302. Belaying pins, used to secure lines on sailing vessels, they could also be used as weapons when necessary:
Larger image
1303. A shingle removing shovel:
1304. A crystal radio:
Larger image
A Philmore crystal radio:
1305. I haven't been able to verify any of these guesses for this device:
-Diffraction grating
-Monochrometer from a spectrometer
-Prism used in a UV-visible spectrophotometer
-Used on an optical table for laser or light work
A view of the back:
1306. A roller type cement jointer, also called a sidewalk groover, sidewalk creaser, or center knife; it's used to smooth the joint between two concrete surfaces.
To submit photos, click on the profile link at the upper right to find my email address.
Last week's set is seen below, click here to view the entire post:
Black Ops Pro Tips
More discussion and comments on these photos can be found at the newsgroup rec.puzzles.


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Home Loan Advice & Mortgage Broking
Whether you are purchasing a new property, or looking to refinance your current home loan, YOLO Home Loans can help find an option that best suits your needs.
Authorised through Connective, YOLO Home Loans has access to over 40 different lenders, and the knowledge to secure the best mortgage solution for you. We can provide credit advice, and implement all debt-related advice contained in your YOLO plan, while structuring your loan in the most cost and tax effective way.
We can also find the best lending available for your vehicles, your business and all other credit requirements. We will help you to determine whether borrowing is the right solution in each case.
To provide you with the best possible service, we offer ongoing advice and support regarding your loan, including monitoring your banking needs to ensure your debt strategy remains relevant and effective.


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Raglan-Manu Bay Surf Forecast and Surf Reports
(Raglan and West Waikato, New Zealand)
- Forecast
- Maps
- Live
- Weather State
- Spot Info
Raglan-Manu Bay Spot ID
Photo credit: ColH
Photo credit: ColH
Photo credit: mattes
Photo credit: jim van kennen
Photo credit: Durand Coldicott
Type: point
Reliability: fairly consistent
Best: Swell SW | Wind SE
Sea Temperature Today is: 13.3 °C
|Friday 17
|Wave (m)
|Period (s)
|Wind (km/h)
|Wind State
View detailed 48hrs and full 7 days forecasts
Raglan-Manu Bay in West Coast Auckland is a quite exposed point break that has fairly consistent surf and can work at any time of the year. Offshore winds are from the southeast. Waves can be ok even in light onshore winds Most of the surf here comes from groundswells and the best swell direction is from the southwest. The beach breaks consists of lefts. Best around low tide. Sometimes crowded. Take care of rocks and locals.
Tide Times:
For Raglan, New Zealand, 5 km from Raglan-Manu Bay.
|IS AT (local time)
|high tide
|low tide
Raglan-Manu Bay Tide Times and Tide Chart
Live Weather:
At Whatawhata, 32 km from Raglan-Manu Bay.
|Air temperature
Overall Raglan-Manu Bay Surf Consistency and Wind Distribution in August
The rose diagram shows the combination of swells directed at Raglan-Manu Bay through an... (show all text)
This picture illustrates how often and how strongly the wind blows from different direc... (show all text)
The two graphs above are also combined in the single Raglan-Manu Bay surf consistency graph.
Also see Raglan-Manu Bay surf quality by season and Raglan-Manu Bay surf quality by month.
|Roads & Rivers:
|Select a surf spot from the menu
Use this relief map to navigate to Raglan and West Waikato surf spots and tide stations that are in the area of Raglan-Manu Bay
Visitor Reviews of Raglan-Manu Bay
"Crowds have really hit this place over the last couple of years. Lovely place now starting to head the way of other well known spots around the world."
David from NEW ZEALAND - 16 Mar 2018
Click here to read 2 more review(s) of Raglan-Manu Bay or submit your own
Other Nearby Surf Breaks closest to Raglan-Manu Bay:(click location name for more details)
- Closest break0 mi
- Second closest break1 mi
- Third closest break2 mi
- Fourth closest break6 mi
- Fifth closest break30 mi
Wave buoys nearest to Raglan-Manu Bay:
- Closest wave buoy1861 mi
- Second closest wave buoy3112 mi
- Third closest wave buoy4044 mi
- Fourth closest wave buoy4063 mi
- Fifth closest wave buoy4196 mi
Tide stations nearest to Raglan-Manu Bay:
- Closest tide station3 mi
- Second closest tide station12 mi
- Third closest tide station17 mi
- Fourth closest tide station29 mi
- Fifth closest tide station54 mi
Town and city forecasts close to Raglan-Manu Bay:
- Closest city location26 mi
- Second closest city location58 mi
- Third closest city location63 mi
- Fourth closest city location69 mi
- Fifth closest city location71 mi
- The closest passenger airport to Raglan-Manu Bay is Hamilton Airport (HLZ) in New Zealand, 44 km (27 miles) away (directly).
- The second nearest airport to Raglan-Manu Bay is Auckland International Airport (AKL), also in New Zealand, 90 km (56 miles) away.
- Third is Tauranga Airport (TRG) in New Zealand, 121 km (75 miles) away.
- Rotorua Airport (ROT) in New Zealand is 134 km (83 miles) away.
- New Plymouth Airport (NPL), also in New Zealand is the fifth nearest airport to Raglan-Manu Bay and is 144 km (89 miles) away.
This is the Surf-Forecast page for Raglan-Manu Bay, Raglan and West Waikato. Use the tab navigation above to view Raglan-Manu Bay sea temperature, Raglan-Manu Bay photographs, Raglan-Manu Bay detailed swell predictions, wind and weather forecasts, Raglan-Manu Bay webcams, current wind from Raglan and West Waikato live weather stations and Raglan-Manu Bay tide predictions. The New Zealand swell maps link will open up the big picture showing New Zealand and the surrounding seas. These swell maps can be animated to show the different swell components, wave energy, wave period, wave heights, together with wind and weather forecasts, current weather and sea state observations from New Zealand wave-buoys, passing ships and coastal weather stations. Each of the forecast pages for this surf break feature a global and regional wavefinder tool to locate the best surf conditions in the area around Raglan-Manu Bay.


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| EJF Home | Find Help | Join the EJF | Comments? | Get EJF newsletter |
| Families And Marriage Book | Abstract | Family site map | Family index |
| Chapter 8 Child "Protective" Services Who's Minding The Minders? |
| Next Infant Discovered In Barn, Child Protective Services Launch Probe |
Background and history
Hillary to the "rescue"
Collateral damage the death of childhood
What is being done to correct this evil?
Child welfare systems don't work by Richard Wexlar
Erin Pizzey
As usual with do-good, touchy-feely federal and state programs, the unintended consequences often, one might say always, outweigh the good such acts are supposed to accomplish.
That is particularly true with what is known in most states as "Child Protective Services," or CPS, usually run under a Department of Human Services or similar misnomer in individual states. Phyllis Schlafly describes them as
"...a vast army of tax-salaried people who would like to expand their ranks, their pay, and their turf. The key to doing that is to have more social problems that require more care and more counseling. It is a bureaucracy that feeds on itself."
The origin of the 21 st Century disasters associated with CPS are usually traced back to Senator Walter Mondale's Child Abuse Prevention and Treatment Act of 1974 (CAPTA '74) and those interested in more history should review the Wikipedia article.
Soon after came the Adoption Assistance and Child Welfare Act of 1980 (ASFA) passed to correct or alleviate problems in the foster care system introduced by the Mondale Act (CAPTA '74). Another stated goal of this second round of legislation was to promote permanency rather than multiple foster placements; and to encourage social workers to work toward reunification of the family, i.e., to promote profitable adoption rings using kids CPS had taken forcibly from their parents. Officially, as contrasted with reality, the plan was that if the child, who had been "legally" kid-napped, could not be returned to the family, another plan was to be sought: adoption, long-term foster care or some other resolution for which CPS was richly rewarded with federal funds.
ASFA required all states to establish an adoption subsidy program and remove the financial disincentives to states by providing federal dollars to be used as a portion of adoption subsidy payments for children previously eligible for the Title IV-E Foster Care Program. Since financial rewards were offered if the children could be quickly adopted, not surprisingly CPS now very frequently found that the children they had kid-napped could not safely be returned to their parents.
Well, that didn't work so well as far as citizens and parents were concerned. So then came the Adoption and Safe Families Act of 1997 (PL 105-89, ASFA) enacted in an attempt to correct problems inherent in the foster care system that deterred the adoption of children with special needs. Obviously, many of these problems stemmed from the earlier Adoption Assistance and Child Welfare Act of 1980.
Naturally, these problems could not have been anticipated when the 1980 law was passed by anyone with an IQ above 80. But bear in mind we are talking about the Congress of the United States.
States decided to interpret AFSA as requiring biological families be kept together almost no matter what. What an idiotic idea! Keep families together! Who would have thought! How could CPS grow and control parents and children if they had to do that?
AFSA was considered the most sweeping change to the U.S. adoption and foster care system in some two decades of social disasters. And who was responsible and what were they thinking? One of AFSA's lead sponsors, Republican Senator John H. Chafee of Rhode Island, stated, "We will not continue the current system of always putting the needs and rights of the biological parents first...It's time we recognize that some families simply cannot and should not be kept together." Naturally, Big Sister knows best as to which families the State can permit to raise their own children.
Ideas for AFSA originated with both Democrats and Republicans but all due credit should be given to then First Lady Hillary Rodham Clinton. Mrs. Clinton originally voiced interest in the issue of orphaned children in an article she wrote in 1995. She then held public events to give the issue exposure, and met with U.S. Department of Health and Human Services officials and private foundation executives over policy questions and recommendations. Then in 1996 she published her screed It Takes A Village telling the world how wonderful communal living is if Big Sister has control of our children, or something to that effect.
AFSA began in Congress with bipartisan support but became contentious over issues of terminating birth parents' rights to children and multibillion funding levels for programs to keep children out of foster care. Hillary Clinton played a key role in finding a compromise between Republicans and Democrats on the latter issue after negotiations first broke down. So clearly we can lay much of the responsibility for the current CPS nightmare on Hillary's doorstep.
But the biggest change was how ASFA amended Title IV-E of the Social Security Act regarding funding. More money for bureaucracies has always been a favorite of the United States Congress. All it took was Hillary's intervention to convince even Republicans that more money should be spent to take children from their parents and destroy families, a course change Republicans have yet to reverse. This nightmare is now bleeding the Social Security system (the American taxpayer) for more than $7 billion a year.
Now it is obvious that some children should not be left in the care of some parents, typically single mothers, but the passage of these laws allowed, even encouraged CPS dimwits to let the exceptions define the rules. Like virtually all dogma-driven radical feminists, they cannot distinguish between possibility and probability. And the CPS empire certainly grows much faster if the rules are based on low-probability events.
Moreover, AFSA marked a fundamental change to child welfare thinking, shifting weight towards children's health and safety concerns, the now notorious "best interest of the child" standard, at the expense of reuniting children with birth parents by helping the parents. The "best interests of the child" saying in social work terms is like "abracadabra" to a magician. This phrase causes sheriffs, judges, lawyers, and professionals that deal with children to cringe and agree unreservedly with every word that child "protective" services (CPS) say like they have no will or mind of their own.
Of course helping the parents and keeping families together is much cheaper than subsidizing adoption and foster care but the destruction of families is an avowed goal of neo-Marxist radical feminists (redfems). And, from a bureaucrat's standpoint, AFSA was a godsend that allowed their empires to grow almost unchecked.
Obviously, only CPS social workers know what is best for a child, particularly if they can depend on anonymous tips and define everything that ever happens to a child as abuse. God forbid that a parent discipline a child in any fashion, e.g., spanking, not approved by the latest psychobabble social "theories." But before adopting that belief system one should note that many, if not CPS caseworkers are often young, poorly educated (one might say indoctrinated) females with no children of their own to provide real-life perspective. However, they are eminently qualified in their own minds to determine how everyone else's children should be treated in every case. And no one has yet had the fortitude to point out that CPS agencies commonly have a turnover of 100% or more a year so that desperate parents trying to get their kidnapped kids back often have to deal with a whole series of incompetent, unqualified, dimwitted do-gooders who have no idea what the previous case worker did or where the child's records are. Naturally, the indoctrination of these zealots does not allow them to consider the fact that it is most likely the mother who is abusing the children.
What quickly evolved under these misguided programs were investigations, or home evaluations conducted by CPS case workers under color of law but lacking such niceties as search warrants, court orders, warrants, and due process.
CPS "evaluations" of parents commonly involve:
Forced intrusions into homes without a warrant or other authority,
Taking children from their homes or schools without court order or other authority based on little or no evidence of abuse or neglect;
Character assassination,
Hiding or "losing" exculpatory evidence,
Fabricating evidence,
Bald-faced lies in affidavits and sworn testimony in court,
Holding kids hostage to coerce cooperation by the parents,
Obstructing parents until 15 of the 22 months clock tolls for automatic Termination of Parental Rights (TPR).
To support this kidnapping and adoption for profit scam we have revived the Star Chamber concept, though they are now called "family courts." Of course, the objective of these courts is anything but the preservation and assistance of marriage and families, and everyone in the court is part of the prosecution except the parents and their children. Naturally, everyone in the "family court" also has legislated immunity except those brought before the bar for child abuse or neglect.
As noted above, child abuse and neglect are now anything and everything that may happen to a child or a family. So in the Kafkaesque world of CPS every natural parent is guilty and every "approved" foster and adoptive parent is innocent.
If parents find themselves out of their home due to money, fire, or flood, under current policies CPS will abduct their children and terminate parental rights. But being poor is not a crime or abuse. Actually, under Title IV-E, CPS is supposed to pay for housing in order to ameliorate said condition, but CPS isn't likely to tell parents that. If CPS finds a condition like homelessness where children are involved, or children need food or clothing, by most state and certainly federal statute CPS has to pay for it, all of it, but they rarely do so from all reports other than those they generate themselves.
In 2009 the Congress gave even more draconian powers and poured more money into CPS. The results are reviewed in the other articles, e.g., the one below, in this chapter by a variety of authors. And if these actions towards our children don't nauseate and horrify you, may I express doubt as to your humanity.
In December 2011 the Equal Justice Foundation published the article In The Face of Great Evil describing the problems with child protective services in El Paso County, Colorado, after eleven (11) children died in just that one year.
And as the carnage and death of children continues, in December 2012 the Denver Post, in conjunction with 9News, ran an eight-part series, Failed To Death, documenting the deaths of Colorado children and the system failures and shortcomings. The articles note that since 2007, 175 children in Colorado have died of abuse and neglect after being beaten, starved, suffocated, and burned. Deepening the tragedy is that the families or caregivers of 72 of these children were known to caseworkers whose job was to protect them.
My Turn, Denver Post
January 29, 2010 Ever since the great "state vs. county" debate broke out [in 2009] over Colorado child welfare, I've maintained it's a sideshow wasting everyone's time and effort. Among the nation's best and worst systems are some run by states and some run by counties.
But if anything could get me to change my mind, it would be the self-satisfied commentary from Donald Cassata, director of the Adams County [Colorado] Human Services Department.
His claim that the system is "not broken" is at odds with everything we know about foster care in general and the Colorado systems in particular. Consider:
The evidence keeps mounting about the enormous harm of tearing children from everyone they know and love and throwing them into foster care. A landmark study of 15,000 typical cases not the horrors that make headlines found that children left with their own parents fared better even than comparably maltreated children left in foster care.
That's because most parents who lose children to foster care are neither sadists nor brutes. Far more common are cases in which family poverty is confused with "neglect."
But year after year, the county-run systems that Cassata defends tear apart families at a rate double the national average.
This does nothing to keep children safer. It only overwhelms child welfare systems, leaving workers less time to find children in real danger. Other states know this. Illinois takes children at one-quarter the Colorado rate, but independent court-appointed monitors found that, as foster care plummeted, child safety improved.
Still another study found abuse in one in three foster homes, a rate consistent with other independent studies, and a much higher rate than reflected in official statistics. It also found that, among foster care alumni, only 20 percent do well as young adults. How can anyone claim a system that churns out walking wounded four times out of five is "not broken"?
Despite Cassata's dismissal of all that pain, I still think the issue of state or county control is irrelevant. But I can think of one Colorado county with a child welfare system that needs new leadership.
Richard Wexler is executive director of the National Coalition for Child Protection Reform.
| EJF Home | Find Help | Join the EJF | Comments? | Get EJF newsletter |
| Families And Marriage Book | Abstract | Family site map | Family index |
| Chapter 8 Child "Protective" Services Who's Minding The Minders? |
| Next Infant Discovered In Barn, Child Protective Services Launch Probe |
Added July 12, 2008
Last modified 4/11/15


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When an ad expires on OLX, sometimes you want to use that again. Maybe it's for an item that you haven't sold yet or a post about your service which already reached it's 28th day of website exposure. Whatever your reason; we have Activate and Refresh.
Activate and Refresh can be used on expired ads to put them back in the listings. Besides this, they also Refresh your ad after 7 days. What this means is they go back to the top of search results and their expiry is reset to 28 days.
NOTE: This button is not available using OLX mobile app.
Click here to find out how to avail Activate and Refresh on OLX.


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Wraithseer & Eldar Corsair Kits
April 5, 2011 by beerogre
First up from Forge World is the Wraithseer kit...
Followed by the Eldar Corsair conversion kit...
These kits will be available at the 2011 Forge World Open Day on April 3rd.
What do you think all you Eldar players?
BoW Andy
Supported by
Supported by


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This site is entirely user-supported. See how you can help.
Street View is the best available vantage point looking, if possible, towards the location of the building. In some locations, Street View may not give a view of the actual building, or may not be available at all. Where it is not available, the satellite view is shown instead.
Latitude: 52.2391 / 52°14'20"N
Longitude: 0.9695 / 0°58'10"E
OS Eastings: 602850
OS Northings: 264255
OS Grid: TM028642
Mapcode National: GBR SHZ.RWH
Mapcode Global: VHKD8.RZDD
Entry Name: Pond Cottage sussex Cottage
Listing Date: 15 March 1988
Grade: II
Source: Historic England
Source ID: 1032698
English Heritage Legacy ID: 280557
Location: Haughley, Mid Suffolk, Suffolk, IP14
County: Suffolk
District: Mid Suffolk
Civil Parish: Haughley
Traditional County: Suffolk
Lieutenancy Area (Ceremonial County): Suffolk
Church of England Parish: Haughley The Assumption of the Blessed Virgin Mary
Church of England Diocese: St.Edmundsbury and Ipswich
4/75 Pond Cottage and Sussex
- Cottage
Two houses: built as one in late C16, subdivided with alterations in early
C19. Alterations of c.1980. Originally of 3-cell plan. 2 storeys. Timber
framed and plastered. Concrete pantiled roof, once thatched; an axial chimney
of early C19 gault brick. Mid and late C20 small-pane casements. Single
storey C20 extensions at either end, containing entrance doors to both houses.
Good quality exposed studding with diamond mullioned window evidence. Within
the early C19 roof there remains an original roof structure, half-hipped at
either end, and with a vestigial queenpost system. Pond Cottage contains the
parlour cell; the original chimney between hall and parlour was removed in C19
and replaced by another in a central position between the cottages. Included
despite C20 alterations because of C16 core, and as an interesting example of
the subdivision of an earlier house into cottages in C19.
Listing NGR: TM0285064255
This text is from the original listing, and may not necessarily reflect the current setting of the building.
Other nearby listed buildings


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TPB takes alleged unregistered tax agent to court
The Tax Practitioners Board (TPB) on 23 February 2012 instituted proceedings in the Federal Court, Brisbane, against Ms Avril Hogan for alleged breaches of the Tax Agent Services Act 2009. The TPB seeks orders including a pecuniary penalty and an injunction against Ms Hogan.
Ms Hogan is alleged to have provided tax agent services to 26 people, including by advising them about their income tax obligations and entitlements and completing and lodging their 2010 returns for a fee while she was not a registered tax agent. That conduct is alleged to contravene s 50-5(1) of the TASA.
To become registered as a tax agent or BAS agent a person or entity must apply to the TPB and meet certain requirements, including a fit and proper person test, and have relevant experience and other qualifications such as the appropriate education.
The TPB's Chair, Dale Boucher said "This legislation is designed to protect taxpayers from unreliable and unqualified tax agents and BAS agents. We strongly urge individuals and businesses only to use registered tax agents and BAS agents."
The public can find out if a person or entity is a registered tax agent or BAS agent, or lodge a complaint, via the TPB's website at www.tpb.gov.au. or by contacting the TPB on 1300 362 829.


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Liposuction London cost may be one of many things you are interested in if you are considering this type of treatment. How much money will you need to set aside? Are there any risks associated with liposuction? How long will it take me to recovery? The list goes on. We aim to answer the most important questions in this blog post. So, let's deal with the financial side of things first. It is impossible to give a definitive answer regarding how much you will pay, as there are a number of contributing factors.
For example, the London liposuction cost you are quoted will depend on the number of areas that are going to be targeted through the surgery, and consequently, how long the treatment will take. Not only this, but also the clinic you choose and their level of experience will also play a role. It is a good idea to get several quotes and compare them. But, don't simply choose the cheapest one, as quality is always the most important. What are the risks of liposuction London wide? This is a low-risk procedure. However, complications that can occur include swelling, dizziness, a bad reaction to medication, excessive bleeding, skin pigmentation, and laxity.
Although these risks are rare, it is important to be aware of them. Luckily, the recovery time is very quick with liposuction, and you will be able to go back to work after a few days. So, if you are interested in this type of cosmetic surgery London based, look no further than Mallucci London. Not only do we have an impeccable reputation in the industry, but also you will struggle to find better liposuction in London prices. For more information, all you need to do is check out our website: https://www.mallucci-london.com. Alternatively, you can book a consultation by giving us a call on 0203 915 7400.


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When Billabong first started its Designer's Closet collection I thought, "Wow, what a great idea!" Then I saw the clothes. . . After seeing the finished products and noticing that most of them were a little scary I strayed away from browsing that particular collection. Today I returned to the collection for a second review and to my surprise there were a few stylish items. Charmer, Howlin, Miss You & Cassia Shirt
Featured: CharmerXX,
S. Roderick


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Le Soleal Dining Info
Click for Ship Info and Pictures
Please consult onboard literature for updated hours and dress information, as these may be altered by itinerary or captain's discretion.
Gastronomic Restaurant (Main Dining Room)
Cuisine: French, International
Dress Code: Resort Casual
Surcharge: No
Reservations Required: No (Open Seating)
Check onboard for hours
Grill Restaurant
Cuisine: French, International
Dress Code: Resort Casual; Jacket/Cocktail Dress recommended for Captain's Gala (once per sailing)
Surcharge: No
Reservations Required: No (Open Seating)
Check onboard for hours
In addition to the restaurants mentioned above, Le Soléal also offers room service, available 24-hours a day. Breakfast is available either buffet-style in the main dining room, or can be delivered to your stateroom upon request.
Speak to an Alaska Cruise Specialist
|Click to inquire about an
Alaska cruise via email
Mon-Fri 5:30am to midnight, Sat-Sun 7am to 10pm, U.S. Central Time


text:
|Sengoku Horizon
|Help Search Members Calendar Affiliates Shoutbox
|Welcome Guest ( Log In | Register )
|Resend Validation Email
Posted: Dec 26 2015, 08:46 PM
Group: Admin
Posts: 2282
Member No.: 1
Joined: 18-November 15
Awards: None
Azai Nobuyori of the Azai Clan
HAIR: Medium length dark brown hair colored blonde.
EYES: Dark Brown
HEIGHT: 174 cm or 5 feet 7 inches
WEIGHT: 65 kg, or 143 lbs.
BODY TYPE: Average leaning towards slim. Must of his extra weight is on the sides of his stomach.
STYLE: Nobuyori's casual gear consists of black pants, some nice black loafers, and a nice blue and white shirt with golden sparrows etched into it and the Azai clan symbol on the back. Over his outfit he usually wears a long, colored, light blue jacket with a golden Azai family crest on the back of the jacket and golden trim around the edges to demonstrate what family he belongs too.
He carries a blue and white cell phone, a brown wallet with a gold Azai clan crest on it, and a wrist charm made of three gold rings on top of each other tied with brown string given to him by Kaori.
OTHER: Everything he wears has an Azai family crest on it somewhere.
Nobuyori takes his role as a scion quite seriously. Even though he often avoids his classes he trains with using his relic and naginata daily. With the Azai clan only four generations old he still feels he has a lot to prove and wants to make it clear to everyone how strong he, and in turn his clan, really are. On missions Nobu very much has a paladin mind set. He isn't good at direct offensive combat, however he is skilled in protecting others. Due to this even if he doesn't necessarily like people he is on a mission with he will do his best to fulfill his role as guard/support in the mission and protect them.
In his free time Nobuyori clearly has a more relaxed side to him as well. He can usually be found sitting on the roof to get a good view point of the area. Having grown up in a castle a high view of a city is very relaxing to him.
Nobu isn't the type to have lots of fans or friends, partially due to his ego as a soon to be clan lord, but he is very close to the small group of friends he does make and is often seen going out with either Suishoku, or his little sister Kaori whenever she uses the train to visit Edo. He also cares deeply for the common people. Back him his mother and father both work extremely hard to communicate with and protect the people of Omi, drilling into Nobuyori that without the cooperation of the common people the samurai class can not exist.
STRENGTHS: Nobuyori has great resolve. The fact that the fate of an entire province is on his shoulders also makes it hard for people to shake or scare him. Nobuyori is also well versed in naval combat due to being from Omi and taking part in naval practices on Lake Biwa with his father.
WEAKNESSES: Nobu is used to being brought up in a noble household and having an entire group to look out for him. Because of this adverse weather conditions and spotting traps aren't really his thing. Wouldn't do well in a trapped area such as a rigged house or a mine field. He is also easily angered and taunted when anyone insults his clan or the province they rule.
LIKES: Being on a boat or being near water, tea ceremony, classical music, cute trinkets and stuffed animals, mochi, Suishoku, astronomy, his family.
DISLIKES: Dishonest people, classes, disrespecting of the Azai clan, extremely combat focused people.
AMBITIONS: Become a better head of the clan than his father and show that the Azai deserve a place in the world. Secretly wants to circumnavigate the world, combining his love of sailing and astronomy.
FEARS: The thought of the Azai clan losing power. Becoming a terrible leader of the clan.
If you'd like to be a traditional student you may delete everything in this section after "weapon"
WEAPON: Brown poled naginata with gold flower designs on the shaft.
RELIC: A series of paper talismans created by the Azai clan. The Azai had always taken ceremony and ritual to be very important. Thus, magical charms and prayers have always been a key part of their clan.
RELIC OWNER: Azai Nagamasa
OWNER HISTORY: At a young age Nagamasa convinced a number of his father's retainers to politely ask his father to step down and let Nagamasa become lord of the province.
Upon becoming lord of his province Nagamasa became married to the younger sister of Oda Nobunaga, Oichi. The two of them had three famous daughters know for their beauty who ended up marrying three famous generals.
Eventually, however, due to Nobunaga attacking the Azai's allies the Asakura, Nagamasa went to war with the Oda. As the Oda surrounded his castle Nagamasa sent Oichi and the three daughters out to the Oda clan before dying in his castle as it burned to the ground.
Nagamasa went down in history as being famous for his love of Oichi and being a lord well loved by his people.
ACTIVATED ABILITY 1: Nobuyori throws a talisman that attaches to an injured person. Slowly restores a small bit of health over two rounds. Heals light damage but doesn't work on life threatening wounds. Mostly used to stop bleeding from wounds and injuries.
ACTIVATED ABILITY 2: Nobuyori throws two talismans in front of himself that glow light blue and float in mid air. From both talismans a wide spread of water bullets starts firing. This lasts for two rounds directly in front of Nobuyori's position when he uses the technique. It makes advancing towards him and attacking from the front very difficult and possibly quite painful depending on the person's armor.
ACTIVATED ABILITY 3: Nobuyori spreads three talismans in front of himself that then form a very large, translucent water barrier in the shape of the Azai clan crest in order to block a powerful incoming attack. Can cover Nobu and as well as people to the sides of him. Can be used up to three rounds. Cooldown starts after shield vanishes.
PASSIVE 1: The Naginata itself has some of Nobu's talismans on the shaft. This causes the blade's edge to have a thin, very sharp edge of water in front of it. This way the blade is considerably sharper than a normal naginata and also doesn't wear as easily since the water is hitting the target instead of the blade.
PASSIVE 2: The inside of Nobu's outfit is laced with talismans, they create a thin veil of water around Nobuyori that helps lower the damage of fire and energy attacks.
LOCKED Awakened Mode Color: bright white
AWAKENED ATTACK: Nobu throws six talismans around the enemy. The talismans start glowing and turn into giant lotus petals. The six petals then envelop a small area and explode with tremendous, hot force. Afterwards a light rain falls for about three rounds.
• Azai Kazuki: Nobuyori's father. A man who is a descendant of an Azai branch family. His grandfather decided to revive the Azai name. In truth their bloodline is fairly muddled.
• Azai Tomiko: Nobuyori's mother. The lady Azai often rules over Omi while her husband is away. Despite being a noble woman she has an obvious tan and tough skin. She firmly believes that simply ordering people around accomplishes nothing and true achievements are done with one's own hands. Due to this attitude she is extremely respected by the people of Omi.
• Azai Kaori: Nobuyori's little sister. She goes to a normal school and shows no interest in things like military and government. She is a middle schooler with short brown hair and dark brown eyes. Tanned skin and a bright smile, she is one of the main people Nobuyori fights for.
•Yamazaki and Murata: Two large guards back home in Omi that have protected Nobuyori and his sister since the two could crawl. The guards had been personally hired by the lord Azai who wanted to give a chance to two Korean immigrants. Both men have since started families of their own and are quite well paid by the clan.
• Suishoku: Nobu's closest friend at the academy. [/blockquote]
BACKGROUND: The Azai clan is a clan trying to prove it's worth. During the sengoku era the Azai clan was crushed after betraying the Oda clan. Azai Nagamasa took his own life, and his daughters became the wives of famous leaders during the sengoku era. Now, skip forward 300 years. Azai Nobuyori's great grandfather, Azai Tsukemasa, decides to ask the Tokugawa family to resurrect the Azai clan after the clan placed in charge of governing Omi do a terrible job for decades on end. The Tokugawa grant his request and the Azai clan is restored and placed in charge of the province. The Azai had also been given the official title of guardians of Lake Biwa and told to help the shogunate conduct naval training on the large inland lake. Thus the Azai clan have served as a naval family for the past three generations going from Nobuyori's great grandfather, and to his father, and someday himself.
Nobuyori, being the son of a daimyo, grew up extremely privileged. Everywhere he or his sister Kaori went they had two armed samurai following them and driving them. On top of that many people bowd in respect when their family entered a building or festival. This caused Nobu to have a large chip on his shoulder when it came to his sense of self worth, even though his mother who was born a commoner and strongly believed in self reliance tried teaching him otherwise. Even though he went to public school with the other kids from Omi his bodyguards hung around the school, and in class he was given special attention. He was also given tutors whenever needed. Due to this he managed to get through public schooling fairly easy, though he made no actual friends while doing so. The children found him too rude and demanding, and so while Kaori got along with people and made plenty of friends, Nobu never really had any.
Around the end of middle school Nobuyori was also given a gift from his father. It was a set of paper talismans that had been made by the Azai clan during the sengoku era. Over all the talismans had no real value. It was simple a symbolic heirloom. However, upon holding them Nobu felt something click with them, and the talismans began glowing. It was soon discovered Nobuyori was able to bond with his sacred item. The gift given from his mother, wasn't as spectacular sadly. The naginata was mostly considered a weapon used by females, however since Nobuyori wasn't particularly physically strong and his father was usually away doing naval operations for the shogun, his mother taught both him and Kaori how to use the weapon.
Eventually Nobuyori found himself, like the children of all provincial lords, sent to Edo Bugei. It is the school his father went to, and thus he had too. At Edo Bugei Nobuyori went from being a one of a kind lord's son that everyone had to bow too to being just like everyone else. He quickly found that what made him special was now worthless, and that many lord's children looked down upon the Azai because they felt that what had been resurrected wasn't the actual Azai clan and that Nobu's name was worthless. It also didn't help that he preferred using the naginata, a weapon many considered to be a female's weapon. As the students lashed out at him this caused Nobuyori to double down and be even more clear about his strong pride in his family, telling the students that they clearly didn't understand the strength of the Azai clan. Sadly all this did was create a viscous cycle of arguing and attacking eachother's pride. Eventually, however, he found solace on the rooftop of the school and often spend time up on the roof instead of in class. After all the book work itself wasn't difficult, but he disliked the ridicule. While on the roof he tended to rest, and practice with his sacred item.
While doing training missions though, his sacred item turned out to be well geared for protecting and healing others. Taking this to mind Nobu asked a lot about the guardian path in school. Through his time on the roof, and missions, he became particularly close to a fellow student and made his first real friend. A girl named Suishoku Yuubae. Coming from a common background but having a sacred item she was the first person to actual treat Nobu not like a prince but like a normal person. The two quickly forged a strong bond between them and rumors began to fly about the two of them being a couple. Through his time spent with her Nobu has started outwardly expressing his desire to protect others, instead of simply feeling it internally. With Suishoku's help he also began doing healing and protecting missions in order to get promoted with her to the second year rank. Now on year two of this rank he strives too make it clear to everyone just how strong the future lord of the Azai is and how well he can protect both common people and scions alike with the power of his sacred item.
Azai Nobuyori
The stuck up clan lord who defends the people.
Tagami Yumiko
The adorable poet girl who hates war.
Katayama, Masato
A strategist bent on changing the world.
Posted: Apr 23 2016, 07:12 PM
Group: Admin
Posts: 2282
Member No.: 1
Joined: 18-November 15
Awards: None
Azai Nobuyori
The stuck up clan lord who defends the people.
Tagami Yumiko
The adorable poet girl who hates war.
Katayama, Masato
A strategist bent on changing the world.


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The Marines gave me a really strong sense of discipline and a work ethic that kicks in at my job.
The Marines was a fresh start - that is why they shave your head. I wish they would let you change your name.
Oh, and once, when I was in the Marines, I got a perfect score on my physical fitness test.
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UnitedHealthcare Housing Initiatives
UnitedHealthcare Community & State has also developed a partnership to improve housing stability and conditions for beneficiaries. By partnering with a local homeless coalition in Ohio, they are better able to locate members who are homeless or precariously housed, facilitate supportive housing placement, and engage the care coordination team to connect members to community-based support services. In addition, the Ohio plan is partnering with a supportive housing development with a significant concentration of UnitedHealthcare members to better connect housing managers and social workers with the managed care coordination team. The goal of these partnerships is to provide stable and healthy housing since evidence demonstrates a clear linkage between housing stabilization and reduction in emergency rooms visits, inpatient admissions, and crisis services. To read more about this innovative program, see this brief summary [link].


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Prayer for Guidance and for Deliverance
Of David.
To you, O Lord, I lift up my soul.
O my God, in you I trust;
do not let me be put to shame;
do not let my enemies exult over me.
Do not let those who wait for you be put to shame;
let them be ashamed who are wantonly treacherous.
The psalmist commits his soul to God and declares his trust. In light of the personal losses and social conditions that fall far short of what we would associate with the reign of God, it may be difficult for us to truly do the same! Every religious life that opens itself to the conditions of the world must confront the question: how can I put my trust in God? As long as trust in God means relying on God for our own particular, desired outcomes, we will be disappointed.
Lifting our souls to God and trusting in God leads us into an ever-deepening relationship in which the mysteries of life unfold. As we trust, we let go, look expectantly to the future, without setting requirements for what that future must hold. Instead, we trust the unfolding of the Creator's gift of life. We trust that our own small portion of human experience is already known by the immanent God, the God who has experienced all that humanity experiences as God incarnate, God in human flesh. We are humbled to life our souls to the transcendent God, the mysterious, all-embracing, creative God whose purposes are wider and broader than we can see.
Placing our trust in this God allows us to face squarely the personal losses and social injustices that are often the source of our doubts. Yes, we continue to have our personal hopes and our particular way of fulfilling our vocation for love and justice. But these are tempered by the larger vision, the mysterious leading of God.
Advent is a time for an examination of those things that hold us back from fully trusting God; letting go and living in the comfort that comes from lifting our whole being into God's arms.
Holy God, reassure us by making yourself known in ways broader and wider than we can hope and dream. Amen.


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Reporting to the Expansion Director and the Director of Strategy and Business Development will impact the organization's corporate development by leading and performing planning and structuring of new negotiations, opportunity identifications and new projects. The position will be based in the Company's headquarters in Madrid, Spain.
Essential Duties & Responsibilities
- Lead and perform planning and structuring of negotiations, opportunity identification and enhance the value of the overall business whereby spending 60% of time on execution and 40% on strategy.
- Work with key executive profiles including CEO, board and senior management team to set the overall global business and corporate development and competitive intelligence strategy for the Company.
- Drive strategy to accelerate growth.
- Bachelor's Degree or equivalent required,MBA strongly preferred.
- Requires understanding of consulting services.
- 2-4 years related Corporate Development experience in an international environment.
- Hands-on deal experience.
- Expertise in technology, media, and telecommunications industry
- Possesses thoroughly developed skills regarding strategic alignment, commercial focus and international vision
- Able to use advanced analytics of big data, mining vast amounts of structured and unstructured information and turn them to a commercial advantage.
- Strong grasp of not only the specifics of the market but also prevailing global trends such as digital transformation and the many disruptive forces in play today across all sectors.
- Willingness to travel extensively.
If your profile doesn't fit in these offers, leave us your CV. Thanks you for waiting to be part of IZO.


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Studies Indicate that Stroke Victims Lack a Certain Antibody, Anti-PC
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Researchers at Sweden's Karolinska Institutet have been conducting studies on stroke for many years. Among their findings are studies indicating that stroke victims lack a certain antibody, anti-PC, in their immune systems that normally reduces the risk of arteriosclerosis, a thickening of arterial walls that can lead to stroke.
Their most recent study provides the impetus to move ahead with the development of a preventative vaccine.
The study compared 227 persons who had suffered a stroke during a 13-year period with a control group of 445 sex and age-matched volunteers. Also controlled were other risk factors such as smoking habits, cholesterol levels, diabetes, body mass index, and blood pressure. The researchers showed that the stroke group had levels of PC antibodies 30 percent below the average of the control group. In women who had strokes the level of PC antibodies was almost three times lower than that of the control group.
PC antibodies go to work on phosphorycholine (PC), a class of fat molecules that make up the plaque that form on the inside walls of arteries in arteriosclerosis
So the Karolinska group sees an avenue to prevention of arteriosclerosis and its consequences, including stroke, through the immune system.
We're now examining the possibility of developing new immunological treatments for arteriosclerosis
and stroke, either in the form of a vaccine to stimulate the immune defence, or immunisation through the injection of antibodies," said Professor Johan Frostegård, the study's lead researcher
WebMD.com, October 4, 2010, by Brenda Conaway — After a stroke, you probably have a lot of questions and concerns about how — and even if — you will recover. When will you be able to move your affected limbs? Will you ever be able to speak clearly? Is your independent life gone forever?
"It's difficult to predict precisely how much function a patient will regain after a stroke," says Randie M. Black-Schaffer, MD, MA. Schaffer is medical director of the Stroke Program at Spaulding Rehabilitation Hospital in Boston. "How quickly a patient recovers in the first few weeks," she says, "can give us an indication of how much damage occurred, and we can make some educated guesses based on that."
According to the National Institute of Neurological Disorders and Stroke, how much of your functional ability you recover depends upon the type of stroke you had, how much brain damage occurred from the stroke, your age, and how quickly rehabilitation begins.
Black-Schaffer advises learning all you can about what caused your stroke and what you can do to avoid further health problems. Use the following questions as a guide when you talk with your doctor about what to expect in the months and years ahead.
1. What caused my stroke?
Eighty percent of all strokes occur when blood flow to the brain is suddenly cut off — usually by a blood clot or some other obstruction. This is called an ischemic stroke. A hemorrhagic stroke occurs when a blood vessel ruptures in the brain.
Knowing the type of stroke you had can help your doctor determine the underlying cause. For example, an ischemic stroke may be caused by a blocked artery due to the buildup of plaque — a mixture of cholesterol and other lipids, or blood fats. People with atherosclerosis, or hardening of the arteries from plaque buildup, are more at risk for this type of stroke. High blood pressure is a common culprit in hemorrhagic stroke. Both of these conditions increase the risk of stroke, and managing them can help prevent a second stroke.
2. Am I at risk for a second stroke?
The overall risk of a second stroke is highest right after a stroke. Three percent of survivors have a second stroke in the first 30 days, and one-third will have another within two years.
"However, individual risk factors are highly variable," Black-Schaffer says. "That's why it's vital to talk with your doctor to understand your specific risk factors and develop a plan to minimize them."
High blood pressure is the number one cause of stroke and the biggest risk factor for stroke. Having heart disease, high blood cholesterol, or diabetes also puts you at risk. Lifestyle factors that put you at risk include smoking cigarettes, obesity, physical inactivity, heavy alcohol consumption, and illicit drug use.
3. What can I do to help lower my risk of future strokes?
Ask your doctor what you can do to control high blood pressure and any other medical conditions you may have. Also, discuss how to make lifestyle changes that can help lower your risk of stroke, including quitting smoking, eating a healthy diet, managing your weight, and getting regular exercise.
Quitting smoking is one of the best things you can do for your health. Your stroke risk decreases significantly two years after quitting and reaches the level of nonsmokers after five years.
4. What is the stroke recovery process?
Although your stroke rehabilitation program will be tailored to your specific needs, most people follow a similar path. You'll begin to do assisted exercises in the hospital once your medical condition has stabilized. The goal is to help you regain certain basic functions, such as the ability to eat and dress yourself.
From there, you may go to an in-patient rehab facility where you will receive intensive therapy to help you become more independent. Once you are able to return home, you may receive outpatient therapy or home therapy to help you regain as much of your functions as possible.
Formal rehabilitation takes place for about three to six months. But studies have shown that stroke patients who continue to practice the skills they hope to regain continue to see progress long after a stroke has occurred.
5. Who will be on my stroke rehabilitation team?
During your stroke rehabilitation, you will work with a team of specialists to recover as much function as possible and learn ways to compensate for any loses.
- Physical therapists will help you regain your strength and balance so you can walk and become more independent.
- Occupational therapists will work with you on daily living skills such as eating, dressing, and bathing.
- Speech and language pathologists help you overcome difficulties with memory, thinking, speaking, and swallowing.
Depending on your needs, you may see other specialists as well. Be sure to check in with your doctor regularly to discuss how your recovery is going and whether you need additional help.
6. How long will my recovery from stroke take?
Stroke recovery is different for every patient. Although some people with a mild stroke recover quickly, for most stroke survivors, regaining lost skills is a lifelong process.
"While the biggest gains will be made in the first three months after a stroke, patients can continue to recover some function, even years later," Black-Schaffer says. "The key is to get into a daily pattern of exercise."
7. Am I at risk for depression after a stroke?
Becoming depressed after a stroke is very common. So ask your doctor about the symptoms of depression so that you and your caregivers know what to look for. Post-stroke depression is thought to be caused in part by biochemical changes in the brain. It's also a completely normal reaction to the losses caused by a stroke. Whatever the reason, treatment is essential. Fortunately, depression can be effectively treated with medication and/or counseling.
8. What medications will I be taking and do they have any side effects?
Strokes are most often caused by blood clots, so your doctor will probably prescribe anticoagulant or antiplatelet medication, commonly known as blood thinners, to help prevent future strokes. You may also need to take medications to help lower high blood pressure or high cholesterol, treat a heart condition, or manage diabetes.
Be sure to talk with your doctor about your medications so that you understand why you are taking them. Ask about potential side effects and possible food and medicine interactions. To help you keep track, you or your caregiver should write down the name and dose of all your medications, including when and how to take them.
9. When should I call my doctor?
Talk with your doctor about what symptoms or situations may indicate a call. However, if you notice any of the following signs of stroke, call 911 immediately. Don't delay — minutes count when it comes to preventing damage from stroke.
- sudden numbness, paralysis, or weakness, especially on only one side of your body
- sudden dizziness, problems with walking, or loss of balance or coordination
- sudden changes in vision
- drooling or slurred speech
- sudden confusion or difficulty speaking or understanding speech
- a sudden, severe headache that is different from past headaches or has no known cause
10. Where can I get support as a stroke survivor?
Getting support from other stroke survivors can help with your recovery. You can contact the American Stroke Association at 1-800-242-87218721 for help in finding a support program in your area or to find out about online support groups. Another resource for finding out about support groups is the National Stroke Association. Their phone number is 1-800-787-6537
Cholesterol-Lowering Statins 'Cut the Danger of Stroke by 20 Per Cent'
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Statins reduce the risk of having a stroke by around a fifth, studies show (file picture)
DailyMail.com — Statins reduce the risk of strokes by about a fifth, a review has shown.
It examined the results of 24 separate studies investigating the cholesterol-lowering drugs, and involving more than 165,000 patients.
The researchers found that the risk of having a stroke fell by 21 per cent for each one millimole per litre decrease in the level of 'bad' low-density lipoprotein (LDL) cholesterol in the blood.
And they revealed that statins not only lowered the overall risk of stroke, but also slowed the progression of blockages in the carotid arteries carrying blood to the brain.
One study found that using statins reduced the risk of recurrent strokes by up to 16 per cent.
Previous evidence had suggested only an inconsistent or weak connection between cholesterol levels and stroke risk.
Writing in The Lancet Neurology journal, the researchers from Paris-Diderot University in France, concluded: 'Lipid ( blood fat) lowering with statins is effective in reducing both initial and recurrent stroke.
'Because this effect seems to be associated with the extent of LDL cholesterol reduction, the next step is to assess the effectiveness and safety of further reductions in LDL cholesterol after a stroke.'
Drug treatments to raise levels of 'good' cholesterol, or highdensity lipoprotein (HDL), might also reduce the risk of stroke, the authors suggested.
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My friend sent this to me and encouraged me to post it and spread the word. I agree. If everyone can remember something this simple, we could save some folks. Seriously.. Please read:
During a BBQ, a friend stumbled and took a little fall – she assured everyone that she was fine (they offered to call paramedics) and that she had just tripped over a brick because of her new shoes. They got her cleaned up and got her a new plate of food. While she appeared a bit shaken up, Ingrid went about enjoying herself the rest of the evening. Ingrid's husband called later telling everyone that his wife had been taken to the hospital – (at 6:00 pm, Ingrid passed away.) She had suffered a stroke at the BBQ. Had they known how to identify the signs of a stroke, perhaps Ingrid would be with us today. Some don't die. They end up in a helpless, hopeless condition instead. It only takes a minute to read this…
A neurologist says that if he can get to a stroke victim within 3 hours he can totally reverse the effects of a stroke…totally. He said the trick was getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours, which is tough.
Have the sense to remember the "3" steps, STR. Read and Learn! Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke. Now doctors say a bystander can recognize a stroke by asking three simple questions:
|Ask the individual to SMILE
|Ask the person to TALK, to SPEAK A SIMPLE SENTENCE
(Coherently) (i.e. . . It is sunny out today)
|Ask him or her to RAISE BOTH ARMS
*NOTE: Another 'sign' of a stroke is this:
Ask the person to 'stick' out their tongue. If the tongue is 'crooked', if it goes to one side or the other, that is also an indication of a stroke. If he or she has trouble with ANY ONE of these tasks, call 911 immediately and describe the symptoms to the dispatcher.
STROKE: Remember The 1st Three Letters… S.T.R.
My friend sent this to me and encouraged me to post it and spread the word. I agree. If everyone can remember something this simple, we could save some folks. Seriously.. Please read:
During a BBQ, a friend stumbled and took a little fall – she assured everyone that she was fine (they offered to call paramedics) and that she had just tripped over a brick because of her new shoes. They got her cleaned up and got her a new plate of food. While she appeared a bit shaken up, Ingrid went about enjoying herself the rest of the evening. Ingrid's husband called later telling everyone that his wife had been taken to the hospital – (at 6:00 pm, Ingrid passed away.) She had suffered a stroke at the BBQ. Had they known how to identify the signs of a stroke, perhaps Ingrid would be with us today. Some don't die. They end up in a helpless, hopeless condition instead. It only takes a minute to read this…
A neurologist says that if he can get to a stroke victim within 3 hours he can totally reverse the effects of a stroke…totally. He said the trick was getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours, which is tough.
Have the sense to remember the "3" steps, STR. Read and Learn! Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke. Now doctors say a bystander can recognize a stroke by asking three simple questions:
Ask the individual to SMILE
Ask the person to TALK, to SPEAK A SIMPLE SENTENCE
Ask him or her to RAISE BOTH ARMS
*NOTE: Another 'sign' of a stroke is this:
Ask the person to 'stick' out their tongue. If the tongue is 'crooked', if it goes to one side or the other, that is also an indication of a stroke. If he or she has trouble with ANY ONE of these tasks, call 911 immediately and describe the symptoms to the dispatcher.
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- Ischaemic Stroke
- Haemorrhagic Stroke
By Beth Anne Piehl, Special Projects Editor — Every second, a person in the world suffers a devastating stroke. In the U.S. alone, approximately 700,000 people experience a stroke annually.
The good news: There are 5.7 million stroke survivors in this country, due in part to advanced training of doctors and nurses, improvements in medical technology and medication and awareness in the general public of the signs and symptoms of stroke that allow for immediate treatment.
Elaine Siwiec, neurology nurse clinician at Northern Michigan Regional Hospital, offered insight into the causes of stroke, risk factors and treatment options, in a Q&A with the News-Review.
PNR: How does a person know if they are having a stroke?
Siwiec: You need to be familiar with the signs and symptoms of stroke. (They include) sudden onset of numbness or weakness of the face, arm or leg on one side; confusion, trouble speaking or understanding; trouble seeing in one or both eyes; trouble walking, dizziness, loss of balance or coordination; and severe headache with no known cause.
Because this is a lot to remember, we teach the Quick Check for Stroke:
F = Facial droop — have the person smile
A = Arm drift — have the person extend their arms and look for a drift
S = Speech abnormal — have the person say something and listen for slurred speech, not using the right words or not speaking at all
T = Time to call 9-1-1.
It is important to recognize symptoms of stroke quickly since the brain ages 3.6 years each hour without treatment.
PNR: Who is most likely to be affected by stroke?
Siwiec: Stroke is more prevalent in blacks (6.8 percent) than whites (2.9 percent) or other races (3.9 percent).
A higher percentage of females reported having had a stroke than males, 3.8 percent and 3.1 percent, respectively. (Statistics from the Michigan Department of Community Health, 2008 report.)
To not understate the problem, each year about 700,000 people experience a new or recurrent stroke. Every 53 seconds, or about every minute, someone in the United States experiences a stroke, and every 3.3 minutes, someone dies of a stroke.
PNR: What are the top risk factors? Can a healthy person, too, have a stroke?
Siwiec: High blood pressure is the number one risk factor for both types of stroke (hemorrhagic or bleeding type and ischemic or type caused by a blockage in a blood vessel supplying blood and oxygen to the brain). High blood pressure, also known as hypertension, results in hardening of arteries that supply the body's organs with oxygen and nutrient-rich blood.
More risk factors:
Cigarette smoking;
Physical inactivity;
Too much alcohol;
High blood cholesterol;
Obesity and being overweight.
Although it is much less likely, yes, occasionally healthy people have strokes.
PNR: If you lose an ability after a stroke — paralysis, speech impairment — is it possible to regain through therapy or will there likely always be a limitation?
Siwiec: Yes, it is very possible to regain function after a stroke. We used to think that all recovery occurred within the first three months after a stroke. We now know that is not true and recovery can take weeks to months to even years. Even so, stroke is the number one cause of long-term disability in the United States.
PNR: Is there any way to predict stroke?
Siwiec: There really is no way to know if a stroke is going to occur before the symptoms start. However, even though there are some risk factors that cannot be modified such as age, race, sex and family history, there are a number of things we can do to reduce our risk of stroke:
If you smoke, quit.
If you drink alcohol, do so in moderation — no more than one alcoholic drink a day. Remember alcohol is a drug and as such can interact with other drugs. If you don't drink alcohol, don't start.
Include exercise in your daily routine. Even a little bit of exercise — a brisk walk, bicycle ride, swim or yard work — can make a difference. Adults should engage in moderate-intensity physical activities for at least 30 minutes on five or more days each week, according to the Centers for Disease Control. Before you start a vigorous exercise program, be sure to check with your doctor.
If your blood pressure is high, work with your doctor to control it.
PNR: Explain how the clot-busting drug works, the time frame for its administration and why it is critical. Can it "reverse" a stroke and its damage?
Siwiec: In 1996, the FDA approved the drug t-PA that can reverse the effects of a stroke caused by a blocked blood vessel (ischemic). The drug must be given within three hours of onset.
Many people ignore the symptoms and don't get to an emergency room in time to receive the medication.
TPA works by dissolving the clot which has blocked the artery causing the stroke and hence blood is re-supplied to the brain before nerve cell death has occurred. It can result in miraculous recoveries in many patients, but not necessarily all.
Although the drug can be given up to three hours after onset of symptoms, the sooner you get it the better your chances for improvement. Also, many tests have to be performed before administering the TPA, so showing up at the ER at three hours would actually be too late.
PNR: How is Northern Michigan Regional Hospital a leader in stroke treatment and patient care?
Siwiec: NMRH earned re-certification or the Gold Seal of Approval from The Joint Commission as a Primary Stroke Center. The Joint Commission's Certificate of Distinction for Primary Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care.
Achievement of certification signifies that the services provided have the critical elements to achieve long-term success in improving outcomes.
PNR: Any final thoughts for people to remember about stroke?
Siwiec: Transient ischemic attack, or TIA, is sometimes referred to as a mini-stroke. You experience the symptoms of a stroke, but the symptoms last a few minutes to no longer than 24 hours. It is a warning that you are at high risk for a stroke, so:
T = Take
I = Immediate
A = Action
Don't ignore your symptoms.
Stroke defined
A stroke is sometimes thought of as a "brain attack." A stroke occurs when a blood vessel or vessels that carry oxygen and other nutrients to a specific area of the brain become blocked or suddenly burst. This interrupts blood flow to the brain and prevents oxygen from getting to where it's needed. When the oxygen supply is cut off, brain cells begin to die resulting in change or loss of abilities or functions controlled by those cells in the brain.
There are two types of stroke — ischemic (iz-KEE-mik) and hemorrhagic.
About 87 percent of all strokes are ischemic, caused by too little blood supply because of a blood clot in an artery leading to the brain.
The other 13 percent are hemorrhagic, caused by bleeding in the brain when a blood vessel bursts.
Source: Second Chances Study of stroke survivors, www.secondchancesstudy.com
Stroke Survivors, Caregivers and Experts Discuss Life After Stroke
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Click on the links below to view select portions of the Second Chances event and panel discussion or watch the entire event.
The $1,000,000 Genome Interpretation
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By Kevin Davies
Bio-IT-World.com, October 6, 2010 | It is doubtful that the scientists and physicians who first started talking about the $1,000 genome in 2001 could have imagined that we would be on the verge of that achievement within the decade. As the cost of sequencing continues to freefall, the challenge of solving the data analysis and storage problems becomes more pressing. But those issues are nothing compared to the challenge facing the clinical community who are seeking to mine the genome for clinically actionable information—what one respected clinical geneticist calls "the $1 million interpretation." From the first handful of published human genome sequences, the size of that task is immense.
Although early days, a number of groups are making progress in creating new pipelines and educational programs to prepare a medical ecosystem that is ill-equipped to cope with the imminent flood of personal genome sequencing.
Pathologists' Clearing House
The pathology department at one of Boston's most storied hospitals isn't necessarily the place where one might expect to find the stirrings of a medical genomics revolution, but that's what's happening at Beth Israel Deaconess Medical Center (BIDMC) under the auspices of department chairman Jeffrey Saffitz.
"I see this as ground-breaking change in pathology and in medicine," he says.
Together with Mark Boguski and colleagues, Saffitz has introduced a genomic medicine module for his residents (see "Training Day"). And under the stewardship of applied mathematician Peter Tonellato, he is building an open-source genome annotation pipeline that might pave the way for routine medical inspection once whole-genome sequencing crosses the $1,000 genome threshold.
All well and good: but why pathology? "We are the stewards of tissue and we perform all the clinical laboratory testing. This has been our function historically for many years. But we have a sense that the landscape is changing," says Saffitz. Genetic testing, he argues, must be conducted under the same type of quality assessment, regulatory oversight, and CLIA certification as provided by the College of American Pathologists (CAP), "and should be done by physicians who are specifically trained to do this. That's us!"
"The brilliance of that," says Boguski, a pathologist by training, "is that it removes a lot of the mysticism surrounding genomics and makes it just another laboratory test." There's really nothing magical or different about DNA, insists Saffitz. "We regard a file of sequence data as a specimen that you send to the lab, just like a urine specimen!"
BIDMC is a medium-sized hospital that conducts 7 million tests a year. Arriving in Boston five years ago, Saffitz began recruiting visionaries to shape "the future of molecular diagnostics" and help the discipline of pathology become a clearinghouse for genomic medicine in a way that is "going to revolutionize the way we do medicine."
Boguski is best known as a bioinformatician who spent a decade at the National Center for Biotechnology Information (NCBI). He sums up the genomic medicine informatics challenge thus: "You have 3 billion pieces of information that have to be reduced to six bytes of clinically actionable information. That's what pathologists do! They take in samples—body fluids and tissues—and we give either a yes/no answer or a very small range of values that allow those clinicians to make a decision."
Increasingly, he says, pathology will become a discipline that depends on high-performance computing to extract clinically actionable information from genome data. That frightens many physicians, but Boguski cites a precedent. "Modern imaging technology would not be possible were it not for high-performance computing, but it's built into the machine!" he says. "Most practicing radiologists don't think about the algorithms for reconstructing images from the X-rays. Most pathologists in the future won't think about that stuff either—it will just be part and parcel of their trade. Nevertheless, we have to invent those technologies."
Math Lab
Mathematician Peter Tonellato has a deep interest in software systems for the clinic, and formulated the idea of a whole-genome clinical clearinghouse within pathology. "We have to start thinking about genetics as just another component of data information and knowledge that has to be integrated into the electronic health record. Stop labeling genetics as something different and new and completely outside the mainstream medical establishment and move it back into the fundamental foundational effort of medical activity."
Come the $1,000 genome, it will simply make sense to sequence everyone's tumor, he says. Just as pathologists study tissue biopsies under a microscope, "we're going to be sequencing it in parallel and figuring out which pathways and targets are pertinent to that person's condition." Simply doing more specialized tests isn't the solution. "How many tens of millions of dollars and how many years has it taken to validate [the warfarin] test?" asks Boguski. "Multiply that by 10,000 other genes and it simply doesn't scale. We're going to have to look at this in a whole new way."
Tonellato has been funded by Siemens and Partners HealthCare to construct an open-source, whole-genome analysis pipeline. Although not commercially released, the pipeline is built and being used for some pilot projects. He is also partnering with companies—including GenomeQuest—who want to do the sequencing analysis in a best-of-breed competition to establish the most refined NGS mapping utilities and annotation tools. The goal is to annotate those variants in a clinically actionable way down to Boguski's six bytes of information and the drug response recommendation. "We think we're as far forward in terms of doing that in an innovative and pragmatic way as anyone," says Tonellato.
Using the cloud (Amazon Web Services), his team has lowered the cost of whole-genome annotation to less than $2,000. "Everybody talks about the $1,000 genome, but they don't talk about the $2,000 mapping problem behind the $1,000 genome," he says. It takes Tonellato's group about one week using five nodes for the resequencing, mapping and variant calling, while the medical annotation takes three people about a month. High-quality computer scientists have to be paid too, he says. "You can't just talk about the sequencing costs."
Of course, it is most unlikely that hospitals will start running massive NGS and compute centers. "We envision a day where every clinical laboratory in every hospital in this country can do this testing," says Saffitz. "They're not going to do the sequencing, but there'll be a machine where they can basically acquire the data, analyze it, and send a report to the doctor saying, 'This is what we found, this is what it means, this is what you do.'" Where the sequencing is done isn't of great concern. "We actually treat sequencing as a black box," says Boguski. What's important is that the hospital's cost requirements and quality standards (and those of the FDA) are met. But Tonellato reckons it would be "very odd to have U.S. samples sent abroad for sequencing to Hong Kong or India… and then sit around and wait for the CLIA-certified, clinically accurate results to come back to us. That may happen in the future, but we have to get our own house in order first."
Another problem is the current state of the gene variant databases, which Boguski calls "completely inadequate" in terms of clinical grade annotation. Where such a resource belongs is open to debate but Boguski is certain it does not belong with the government. "The government is not a health care delivery organization. Whatever that database is, it needs to operate under the same CLIA standards as the actual tests."
Pathologists have traditionally interacted with patients when they are sick. "But more and more," says Saffitz, "we're going to be analyzing the genomes of people who are well, and I hope assuming a very prominent role in the preservation of health and preempting disease."
Quake Aftershocks
The most comprehensive clinical genome analysis to date was reported in May 2010 in the Lancet. Stanford cardiologist Euan Ashley and colleagues, including Atul Butte and Russ Altman, Stanford's chair of bioengineering, appraised the genome of Stephen Quake (see, "A Single Man," Bio•IT World, Sept 2009). "This really needs to be done for a clinical audience to show them what the future is going to be like," says Altman, who is also director of the biomedical informatics program and chief architect of the PharmGKB pharmacogenomics knowledgebase. The task of interpreting Quake's genome involved more than 20 collaborators, including bioethicist Hank Greeley and genetic counselor, Kelly Ormond. When discussions turned to the risk of sudden cardiac arrest (Quake's family has a history of heart disease), Ormond would invite Quake to leave the room until a consensus was reached.
Altman's own group was able to predict Quake's response to about 100 drugs. Some of it was imprecise, but he realized that, "especially for the pharmacogenomics, we are much closer [to clinical relevance] than I realized." He said he would "bet the house" on the results dealing with statin myopathy, warfarin and clopidogrel dosing. The Stanford team also tried linking environmental and disease risk, but Altman admits that is farther from clinical practice. The Lancet study drew high praise from the BIDMC team. "As good as it gets," is Tonellato's verdict. "But go down to some town in the middle of America and say, 'What are you going to do with this genome dataset for your patient?'… Is medicine ready for genetics yet or not? There is a long way to go."
Since the publication, Altman has received inquiries from companies interested in doing similar "genomic markups" and licensing his group's annotations. Altman intends to hire an M.D. curator to complement his Ph.D. curators, someone who can highlight the clinical significance of research data. Altman says he would be happy to have PharmGKB data included "in any and all pipelines. Meanwhile, Ashley is leading a Stanford program to make a computer pipeline to reproduce the Quake analysis on a larger scale.
In a rational world, Altman says, it seems logical to sequence human genomes at birth and put the data in a secure database, querying it only when you know what you're going to do with the results. That's in an ideal world. In the United States, he notes dryly, some people do not trust governmental databases. "I could imagine if it's cheap enough, that people will actually resequence the genome on a need-to-know basis, simply so they don't have to store it. I think that's a little bit silly, but in order to get genomic medicine effected, I'm not going to lose the fight over the database."
Whoever ends up doing clinical genomic sequencing in the future, Altman says they will have to document high-quality data with a rapid turnaround. "We will then put [the data] through the pipeline—hopefully the Stanford pipeline or whatever pipeline seems to be winning—and then we will query it as needed and as requested by the physicians on a need-to-know basis."
1,500 Mutations
Genome Commons was established by Berkeley computational biologist Steve Brenner to foster the creation of public tools and resources for personal genome interpretation. He wants to build an open access Genome Commons Database and the Genome Commons Navigator. He is also launching a community experiment called CAGI (The Critical Assessment of Genome Interpretation) to evaluate computational methods for predicting phenotypes from genome variation data (http://genomeinterpretation.org).
One notable private effort in clinical genome annotation is that of Omicia, a San Francisco-based software company founded by Martin Reese in 2002.
Omicia is taking genome data and extracting clinical meaning, focusing on DNA variation, rather than gene expression or pathways. "We have one of the best systems for interpreting the genome clinically," claims Reese. He started with Victor McKusick's classic Mendelian Inheritance in Man catalogue, which now lives online as OMIM, mapping a "golden set" of disease mutations to the reference genome. Omicia is also developing algorithms to predict the effect of protein-coding variants to better understand which mutations are medically relevant.
Reese sums up the goal: "You have 21,000 protein coding mutations compared to the reference genome. 10,000 of them are non-synonymous. We have 3,500 in disease genes. That's roughly 15%. So 15% of 10,000 is 1,500 protein coding mutations. The goal is to interpret 1,500 mutations."
For the time being, Omicia is offering its services through collaborations. Reese has a three-year collaboration with Applied Biosystems, and was a co-author on the first NGS human genome paper using the SOLiD platform in 2009. Then there is the Life Alliance, a cancer genome alliance, featuring various medical centers and Life Technologies. "We're doing their interpretation of these cancer genomes for 100 untreatable cancers," says Reese.
Presenting the data for a physician is a challenge, says Kiruluta, but not as bad as the scant amount of time a physician has to see a patient. "The reporting is to help a physician make a decision quickly—green light, red light. Then there's a much more detailed interface behind the scenes," where other medical professionals can study the patient's data in more detail.
Reese sees advantages to the commercial approach for genome software compared to academic solutions. "This will be a big play in next few years as people make clinical decisions. So the quality of the software, the QC of the assembly, how transparent you are, the annotation, is critical. It will be a big problem for academia to do that—you know how it is when a postdoc writes something!"
Reese has also been spearheading the effort to develop a new Genome Variation Format with Mark Yandell (University of Utah) and others, which was recently published in Genome Biology.
DNA Partners
The challenge facing the affable Samuel (Sandy) Aronson, executive director for IT at the Partners HealthCare Center for Personalized Genetic Medicine (PCPGM) and PCPGM's clinical laboratory director, Heidi Rehm, is to deliver clinically actionable information to physicians in the Partners HealthCare network. "This challenge cannot be entirely solved by a single institution," Aronson notes. "It takes a network of institutions working together."
Rehm maintains a knowledge base of 95 genes that are routinely curated by the PCPGM's Laboratory of Molecular Medicine and supplies information to physicians on the status of those genes in their patients in real time. The PCPGM's GeneInsight suite, developed by Aronson's team, has been in use for about seven years. There are two components—one for the laboratory, the other for the clinician. The lab section consists of a knowledgebase—the tests, genes, variants, drug dosing, etc—as well as an infrastructure to generate reports via the Genome Variant Interpretation Engine (GVIE).
On the clinical side is a new entity, the Patient Genome Explorer (PGE), which allows clinicians to receive test results from an affiliated lab and query patient records. "The PGE, without a doubt, is one of its kind," says Rehm. "There's no other system out there. There's a lot of excitement about it. Labs are choosing us for testing because we offer that service." When an update is made to the PCPGM knowledgebase on a variant that is clinically significant, the PGE proactively notifies the clinicians caring for patients with that variant. If there are 100 clinics with 10 patients each, and Rehm updates the knowledgebase, then 1,000 patient updates are dispatched automatically.
For inherited disease testing, the alert changes the variant from one of five categories to another: 1) pathogenic 2) likely pathogenic 3) unknown 4) likely benign, or 5) benign. The PGE made its debut last summer in the Brigham and Women's Hospital Department of Cardiology. When the system launched, a dozen "high alerts" (meaning a variant has shifted from one major category to another) were immediately dispatched. The physicians' response has been really positive, says Aronson. "There's a significant disconnect between the level of quality of data being used for clinical purposes and the quality of data in the research environment," says Rehm. "Our hope with the distribution of this infrastructure is to get more data validated for clinical use."
Core Challenges
The Partners effort is a worthy start, but the larger goal is to build a network where labs with expertise in other genetic disorders such as cystic fibrosis contribute their data, perhaps by offering attribution or a nominal transaction fee. "We can't maintain data on every gene, but we're willing to establish nodes of expertise," says Rehm. As for the IT infrastructure, Aronson hopes to enable organizations to create a node on the network, link to the PGEs, and then operate under their own business models—whatever it takes to make the data accessible. The first external partner that linked to GeneInsight was Intermountain Healthcare (IHC) in Utah. "We believe this is the first transfer of fully structured genetic results between institutions so that they got into IHC's electronic health record and are now available for decision support," says Aronson.
Aronson anticipates a day where whole-genome sequencing for patients will be a clinical reality. "It's very much on our radar," he says, but doesn't appear unduly concerned. After all, he says, the PGE is designed to store highly validated clinical information, and he doesn't expect the millions of variants in a whole genome to contain enough clinically actionable variants to overwhelm the database. The challenge will come in understanding complex/low-penetrance diseases, "where we're more algorithmically dependent. That will require new infrastructure."
A bigger problem is facilitating the business models that will solve personalized medicine challenges. "Our goal is to expand networking, adding labs, PGEs and going after a network effect," says Aronson. "We have a structure that could present an answer to how do you—in a true patient-specific, clinically actionable way that clinicians can use in their workflow—help interpret the data?" •
Training Day
It was in 2009 that Mark Boguski conceived the innovative training program for Beth Israel's pathology residents, and yet remarkably his boss, Jeffrey Saffitz, thinks every pathology department in North America might have introduced a similar program by 2012. The program offers residents the chance to be personally genotyped. It is, after all, a time-honored tradition in medicine for medical students to draw blood and exam each other, so this is nothing new.
Boguski selected Navigenics for the genotyping service because it focuses on medically actionable conditions and has a built-in genetic counseling component. All but two of the 17 BIDMC residents chose to get tested. Afterwards, Saffitz, Richard Haspel and colleagues published a "call to action" for the pathology community in the American Journal of Clinical Pathology. The response was incredibly positive, and many programs are eagerly signing on.
"We want the residents to see that a typical bioinformatics analysis of a genome — pages and pages of text and references using natural language processing or something — isn't going to work," says Saffitz. "We actually use that as a teachable moment to say, 'this is the state-of-the-art today, but here's how we have to move it forward.'"
Stanford has introduced a similar course in personal genomics where students could optionally get genotyped and analyze their genome, allowing the students to calculate their disease risks and optimal drug dosage. "It felt somewhat historic, actually," says Altman. There were divisions among the faculty as to whether it should be offered, but Altman hopes the course will become a staple in the curriculum. K.D.
NIH Press Release
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U.S. Department of Health and Human Services
NATIONAL INSTITUTES OF HEALTH NIH News
NIH Office of the Director
For Immediate Release: Wednesday, October 6, 2010
The 2010 Nobel Prize in chemistry has been awarded to National Institutes of Health (NIH) grantee Ei-ichi Negishi, Ph.D., of Purdue University, West Lafayette, Indiana. Dr. Negishi shares the award with Richard F. Heck, Ph.D., of the University of Delaware in Newark, Delaware and Akira Suzuki, Ph.D., of Hokkaido University, Sapporo, Japan. The three researchers are honored for developing complementary methods to find more efficient ways of linking carbon atoms together to build complex molecules.
"The methodology developed by these stellar scientists has broad implications for the medical, electronic, and agricultural fields," said NIH Director Francis S. Collins, M.D., Ph.D. "It has already allowed chemists to synthesize compounds to fight the herpes virus, HIV, and colon cancer."
Dr. Negishi has received more than $6.5 million in support from the NIH's National Institute of General Medical Sciences (NIGMS) since 1979.
"Carbon-carbon bonds are like the frame of a house — you have to get them right for the structure to be functional and useful," said NIGMS Director Jeremy M. Berg, Ph.D. "By developing more precise and efficient methods for making these bonds, the scientists selected for the 2010 Nobel Prize in chemistry have created a remarkably powerful tool for synthesizing a wide range of useful chemicals."
The Office of the Director, the central office at NIH, is responsible for setting policy for NIH, which includes 27 Institutes and Centers. This involves planning, managing, and coordinating the programs and activities of all NIH components. The Office of the Director also includes program offices which are responsible for stimulating specific areas of research throughout NIH. Additional information is available at <http://www.nih.gov/icd/od/>.
The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit <www.nih.gov>.