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When Diabetic Foot Ulcers Can Be Managed At Home
Approximately 15 percent of all patients with diabetes can be expected to develop ulceration in their lifetime, thus putting them at risk for lower extremity amputation. Treatment for infected diabetic foot wounds accounts for one quarter of all diabetic hospital admissions in the United States and Great Britain.1-3 Patient education, proper footgear and regular foot examination can decrease the frequency and severity of ulceration. However, when ulceration does occur, home care may be a cost-effective intervention that can either avoid or shorten hospital admissions in appropriate cases. Obviously, severe, limb-threatening infection or ulceration requires hospital care. This is especially true in cases complicated by vascular disease that may require angiography and bypass surgery. However, if acute infection has been stabilized and the patient has adequate vascular perfusion (or it has been restored during hospitalization), proper wound care at home can facilitate the completion of wound closure. Such care does require administration of necessary antibiotics, debridement and dressing changes, offloading the ulcerated part, and optimal diabetes management. Evaluating Ulcerations For The Possibility Of Treatment At Home The first step in determining suitability for home care is to establish whether the ulceration is limb threatening or not. A useful system for evaluating the severity of diabetic ulcerations was developed at the University of Texas (see "University Of Texas Wound Classification System" below).4 The classification is based on the depth of the ulceration, presence of infection and degree of ischemia. One will see ischemic ulcers in pulseless feet with thin atrophic skin. These ulcers are usually fibrous or present with an eschar. Little or no granulation tissue is present. Ischemic ulcers are less common than the more typical neuropathic ulceration. Ischemic feet frequently require some form of vascular intervention such as angioplasty or bypass surgery to achieve healing. A Grade III-D ulceration is a deep, infected ischemic ulceration. This ulceration constitutes a limb threatening condition and likely requires hospitalization. Initial treatment includes surgical debridement of necrotic tissue, a bone biopsy and infectious disease consultation to initiate proper long-term antibiotic therapy. Peripheral vascular consultation for angioplasty or bypass surgery may be necessary to achieve healing. If all this is accomplished, one may manage the clean, stable, open wound with home care until closure, which may take six weeks or more. Keep in mind that not all diabetic ulcers are infected. Since most ulcerations are contaminated, cultures are likely to reveal a variety of organisms. The diagnosis of infection depends on clinical signs. These signs may include fever, redness extending from the ulcer site, surrounding edema and purulent drainage. Well-granulated ulcerations that do not probe to bone and exhibit no ascending erythema are not likely to be infected, and do not require antibiotic management. When infection does occur, one should consider the nature of the infection before initiating treatment. Superficial ulcers are typically not limb-threatening when they do not probe to bone and cellulitis is less than 2 cm from the ulceration. Patients who have these ulcers are not seriously ill and there are no signs or symptoms of significant systemic involvement. These patients may do very well with outpatient or home care and oral antibiotics. The American College of Foot and Ankle Surgeons has distinguished between non-limb-threatening infections and limb-threatening infections, advocating that patients with limb-threatening infections be hospitalized, at least initially.5 Patients who have deeper infections that probe to bone and systemic signs such as fever, leukocytosis, hyperglycemia, lymphangitis and edema may have limb-threatening disease. Gangrene, abscess, osteomyelitis and even necrotizing fasciitis may be present. Hospitalization is recommended with the following objectives. One should incise and drain deep abscesses, and debride infected bone and necrotic tissues to viable edges. One usually would do this in the operating room. Obtain deep cultures, perform a bone biopsy and proceed with appropriate antibiotic intervention. If there is an ischemic component, one should obtain a vascular consult. Revascularization procedures are provided if necessary and feasible. Once the patient is medically stable, and the wound appears clean and viable, one may emphasize home care. University Of Texas Wound Classification System4 Grade I-A: non-infected, non-ischemic superficial ulceration Grade I-B: infected, non-ischemic superficial ulceration Grade I-C: ischemic, non-infected superficial ulceration Grade I-D: ischemic and infected superficial ulceration Grade II-A: non-infected, non-ischemic ulcer that penetrates to capsule or bone Grade II-B: infected, non-ischemic ulcer that penetrates to capsule or bone Grade II-C: ischemic, non-infected ulcer that penetrates to capsule or bone Grade II-D: ischemic and infected ulcer that penetrates to capsule or bone Grade III-A: non-infected, non-ischemic ulcer that penetrates to bone or a deep abscess Grade III-B: infected, non-ischemic ulcer that penetrates to bone or a deep abscess Grade III-C: ischemic, non-infected ulcer that penetrates to bone or a deep abscess Grade III-D: ischemic and infected ulcer that penetrates to bone or a deep abscess What You Should Know About Monitoring Infection, Cultures And Antibiotic Selection The principles of treating diabetic foot ulceration can be distilled down to infection control, evaluation of vascular perfusion, optimal metabolic management and pressure relief via offloading. If the infection is not limb-threatening, one may emphasize treatment at home. Using the aforementioned University of Texas evaluation system, the most suitable ulcerations for home care are grade I-A, I-B II-A or II-B. When it comes to grade I-C and II-C ulcers with localized infection, one should take reliable cultures from infected tissues and select an appropriate oral antibiotic therapy based on the culture results. Since grade III ulcerations probe to bone, they are considered, almost by definition, to have osteomyelitis and may require hospitalization to initiate therapy. If osteomyelitis is present, performing bone debridement or obtaining a biopsy is necessary in order to establish the infecting agent. Then one would need to administer long-term (possibly IV) antibiotics.6 The difficulty arises when Grade I and II ulcers are present for a prolonged period of time and deep infection is uncertain. If such an ulcer is present for three months or more, unsuspected osteomyelitis may be present. Obtaining a bone scan or MRI may be helpful to make the diagnosis. One can do this on an outpatient basis for patients without systemic febrile illness. However, be aware these imaging studies are not always conclusive. In highly suspicious cases, one should biopsy and culture the bone underlying the ulceration, and subsequently provide appropriate antibiotic treatment. One may utilize outpatient surgical facilities for this purpose if the patient is stable and you consider the infection to be non-limb-threatening. It is easy to initiate wound care and oral antibiotics in the home setting. If soft tissue infection is present, one should obtain accurate cultures to ensure proper antibiotic therapy. Be aware that an array of organisms can contaminate diabetic wounds. To obtain a reliable culture, one must clean the superficial aspects of the wound and swab the deeper, obviously infected tissues. Samples of deeper or debrided tissue will yield the best bacteriologic information.7 When treating non-limb-threatening infections, one may proceed with empiric broad-spectrum antibiotics (such as cephalosporins, quinolones, or penicillin clavulanate combinations) while awaiting culture results.6 Keep in mind that methicillin resistant Staph aureus (MRSA) is becoming a bigger problem and now there are community-acquired strains of MRSA. If this organism is an infecting agent, IV vancomycin or oral linezolid therapy is indicated. If surgical debridement and long-term IV access is necessary, one can initiate this in the hospital. Once the patient is stable, one can have the patient continue the antibiotic therapy at home. Converting Chronic Wounds Into Wounds That May Be Ready For Home Care One should monitor grade I or II A or B ulcerations for signs of infection and healing on a weekly basis at the least. This can be done by a visiting nurse upon orders from a podiatric physician. If there is no improvement within one or two weeks, and especially if pulses are absent and other signs of ischemia are present, one should obtain a peripheral vascular consultation. Angiography, angioplasty or bypass surgery may be indicated to treat ischemic ulcerations that fail to heal if the patient is a good candidate for such intervention. Keep in mind that even if the patient has adequate perfusion and the infection has been controlled, the ulcer may still fail to heal if the patient has a poor metabolic status. Anemia, poor control of diabetes and nutritional deficits contribute to faulty wound healing. To address these issues, have the patient see a primary physician, internist or endocrinologist.7 Once one has controlled the infection, obtained adequate vascular status and initiated attempts at metabolic control, the wound is ready for home care. Non-infected, neuropathic, non-ischemic ulcerations may present in this condition. Sometimes hospitalization may be required for surgical debridement, initiation of antibiotics or bypass surgery to achieve this appearance. However, once one has brought the wound to a viable appearance, the home is a very acceptable setting for further care. What One Illustrative Case Study Reveals In one case, the patient was a 60-year-old male, who had suffered from type II diabetes for over 20 years. He presented with an infected deep necrotic ulceration of the hallux, which we classified as a III-D ulcer. We performed a hallux and partial first metatarsal amputation to stabilize an acute limb-threatening infection. Our peripheral vascular consultation concurred with the diagnosis of vascular disease, but felt the patient had adequate perfusion for healing. An infectious disease consult recommended six weeks of IV antibiotic therapy based on deep cultures that were taken during surgery and were consistent with osteomyelitis. We stabilized the wound in the hospital to the appearance shown in the above photo with wet to dry saline dressings. The visiting nurse performed wound cleansing and calcium alginate dressing changes every one to two days and monitored for signs of infection. The podiatrist performed debridement every one to two weeks as necessary to maintain a viable wound. The patient used a walker and wheelchair for mobility. In the bottom right photo, one can see the patient's wound after three weeks of home care. In the bottom left photo, one can see the almost healed wound after six weeks of home care. A Closer Look At Debridement, Dressings And Topicals In The Home Setting Debridement, dressings and offloading are well-established principles of wound healing. These latter measures may not require hospitalization and can be performed in a home care setting. Diabetic ulcerations are usually painless and one can debride these through subcutaneous tissue, tendon or muscle, and sometimes even bone without any anesthesia. There is usually an extensive keratosis that surrounds or covers the ulceration. One can usually remove this to the point where only viable, healthy tissue remains. One should proceed to clean the wound with soap and water, sterile water or saline. Debride with sterile forceps, scissors, tissue nippers or a number 15 scalpel. Once the wound bed is clean and free of any non-viable keratosis, fibrous tissue or necrotic tissue or bone, proceed to re-cleanse the foot with sterile water or saline and apply a dressing. (An exception to the need for debridement is the dry, stable, superficial eschar. If there is no evidence of underlying or ascending infection, one should leave such eschars intact to demarcate and slough as the underlying skin epithelializes. As the eschar becomes loose, it may then be appropriate to proceed with gentle debridement.) The type of dressing one uses depends on the condition of the wound. If one would like additional superficial debridement, using a wet to dry saline dressing will accomplish this. If excessive exudate is present, absorptive dressings like calcium alginate preparations are useful. This material will absorb the exudate yet maintain a physiologically moist interface between the wound itself and the dressing material. Generally speaking, dressings that promote moist environments should only cover the wound. One should avoid maceration of surrounding tissues. Topical hydrogels and gauze will also maintain a moist environment in the ulcer without causing maceration in wounds that do not have excessive exudate. While the frequency of dressing change depends on the amount of exudate, it is usually required between two times daily to every other day. If infection is a concern, a visiting nurse should perform the dressing changes and evaluate the patient for signs of infection. If the ulcer is stable, many patients or family members can be taught to do the dressing changes. A variety of topical products are available to facilitate wound care. One may employ topical enzymes when debridement is required beyond what sharp instrumentation can achieve. When the wound is viable and granulated, the enzymes are not helpful. Hydrogels are an economic topical treatment one can use to maintain a proper moist environment. They are easy to apply under a gauze dressing. Platelet derived growth factors, both synthetic and autologous, have been advocated to facilitate and speed up wound healing. These may be helpful after one has achieved adequate debridement and offloading. However, platelet derived growth factors are quite costly to initiate. Some have argued this cost is offset by more rapid healing times. A number of biological and tissue engineered preparations are also available, but may be difficult to use at home due to temperature and storage requirements. Antiseptics, like peroxide or iodophor solutions, are discouraged because their drying effects are thought to impair wound granulation. Key Insights On Offloading Most diabetic ulcers result from excessive plantar pressure. If that pressure continues after ulceration, logic suggests that the ulcer is unlikely to heal, no matter what type of topical applications one utilizes. The most effective offloading technique is non-weightbearing on the ulcerated foot. However, compliance with crutches, walkers or wheelchairs is difficult to achieve. Several alternatives to complete non-weightbearing are available, but they represent a compromise and do not fully offload the ulcerated foot. These alternatives include the total contact cast (TCC), removable cast walker and the half shoe.8 The effectiveness of these devices appears to vary inversely with the ease of application. Armstrong and his group studied the effectiveness of these devices and found the TCC promotes healing ulcers in the shortest time (4.3 weeks). This compared to 5.6 weeks for the removable cast walker and 5.5 weeks for the half shoe.8 However, the TCC is difficult and time consuming to apply. There is also a risk of cast induced ulceration with this technique. Half shoes, other healing shoes and removable cast walkers may be worn over the wound dressing, and should be used with some sort of gait assisting device, such as a cane or walker, to achieve partial weightbearing. If the patient is unsteady or unsure of how to use the offloading devices, home physical therapy for partial weightbearing gait training may be effective. Wheelchairs with leg lifts for the affected extremity allow mobility with effective offloading. One should emphasize making all efforts to facilitate as little weightbearing as possible on the ulcerated extremity. Heel ulceration is a concern with bedridden patients. One should regularly inspect the heels of both feet and make an effort to cushion or offload the heels while the patient is in bed. Major efforts to accomplish the healing of a midfoot or forefoot ulceration can be totally undone if a patient develops a decubitus ulcer. Managing The Potential Treatment Outcomes A typical plantar diabetic ulceration under home care should heal in approximately six weeks if the patient meets the following parameters: a controlled infection; adequate vascular supply; is metabolically stable with a serum albumin or 3.0 or better; has near normal hemoglobin; well-controlled diabetes; and adequate offloading of the ulcer. One should grade and measure the ulcer on a weekly basis to monitor progress. If you do not see gradual improvement, there is a likely deficiency in one of the aforementioned parameters. If the ulcer is granulated and contracting, even if slower than expected, the prognosis is good. Dysvascular, hypoalbuminemic and other compromised patients can still heal but it will likely take longer. If the wound is not deteriorating in any way, it will likely heal eventually. One can evaluate infection by monitoring white blood cell count and sedimentation rate. If the white blood cell count or sedimentation rate is not normal or not demonstrating decreases from the start of treatment, one should suspect osteomyelitis. If one can probe the wound to bone, osteomyelitis is likely. If one cannot probe to bone, it may be necessary to obtain an X-ray or bone scan to establish the diagnosis. If either is positive, institute treatment with bone debridement, biopsy, culture and appropriate antibiotics as previously discussed, continuing with appropriate wound care. Other causes of wound failure include vascular disease and metabolic impairment. Usually, one would identify vascular insufficiency early in the course of care. If borderline vascular disease is present but has not been treated, and the ulcer is not healing, one should obtain a follow-up consultation with a peripheral vascular surgeon. Patients with low albumin, renal disease or poorly controlled diabetes may fail to heal. If one cannot control these processes, continue with wound care indefinitely unless one decides to consider amputation. If there is uncontrollable infection, necrosis of bone or deep soft tissues that cannot be debrided away or intractable ischemic pain, one should consider amputation. Likewise, if the ulcer care is requiring such prolonged disability that the patient's overall quality of life is deteriorating, amputation may be a welcome relief. Initially, many patients will resist the recommendation. However, if amputation can be viewed as a rehabilitation step to improve quality of life, the patient will eventually see the advantage of surgery over an indefinite long-term challenge of chronic wound care. If the ulcer heals successfully, the next challenge is to return the patient to community ambulation and protect him or her from further ulceration. Anytime a patient has developed an ulceration, one should consider the patient at high risk for another ulcer. This is especially true of patients who have neuropathy with lost protective sensation, vascular disease or ulcerative deformities such as severe bunions and chronic pressure callus. Educating the patient about risk and foot care is essential to preventing further ulceration. One should emphasize the importance of regular foot exams. Patients may need accommodative shoes. Some may have ulcerative bony deformities, which may be treated surgically if adequate blood flow is present. Other patients may need help with managing nail conditions or chronic pressure keratosis. One should also inspect a patient's protective shoes and orthotics to ensure their effectiveness. Also ensure the patient is aware that even minor injury can lead to ulceration and infection so he or she should not hesitate to seek medical attention any time the foot appears at risk.9 Final Notes Diabetic foot ulcerations can be successfully managed in the home care setting. This is particularly true in cases where no limb threatening infection is present. In all cases, though, one should emphasize careful, long-term and regular foot examination and care as an integral part of the patient's diabetes management. Dr. Sage is a Professor and Chief of the Section of Podiatry within the Department of Orthopaedic Surgery at the Loyola University Stritch School of Medicine in Maywood, Ill. Dr. Steinberg (pictured) is a faculty member of the Department of Surgery at the Georgetown University School of Medicine in Washington, D.C.
References 1. Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes. Diabetes Care 1998; 21 (12): 2161-2177. 2. Pecoraro RE, Reiber GE, Burgess EM. Pathways to limb amputation. Diabetes Care 1990; 13: 513-521. 3. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Diabetes in America, 2nd edition. (NIH publication number 95-1468), Harris MI, editor, U.S. Government Printing Office, Washington, DC, 1995. 4. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system; the contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21: 855-859. 5. Frykberg RG, Armstrong DG, Giurini J, Edwards A, et al. Diabetic Foot Disorders, A Clinical Practice Guideline. American College of Foot and Ankle Surgeons, Data Trace Publishing Company, PO Box 1239, Brooklandville, MD, 212022-9978, 2000. 6. Eckman MH, Greenfield SG, Mackey WC, Wong JB, et al. Foot infections in diabetic patients, Decision and cost effectiveness analyses. JAMA 1995, 273 (9): 712-720. 7. American Diabetes Association. Consensus development conference on diabetic foot wound care. Diabetes Care 1999: 22 (8) 1354-1360. 8. Armstrong DG, Nguyen HC, Lavery LA, van Schie CHM, et al. Off-loading the diabetic foot wound. Diabetes Care 2001, 24(6): 1019-1027. 9. American Diabetes Association. Preventive foot care in people with diabetes. Diabetes Care 2002, 25 supplement 1: S69-S70.


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Choo continues to deliver in leadoff spot
By Jeremy Warnemuende / MLB.com
CINCINNATI -- Reds center fielder Shin-Soo Choo hit his 15th home run of the season on Saturday night, but it was his first with runners on base. That's often the way it goes for leadoff hitters, but manager Dusty Baker said Choo has made the most of the opportunities he's had to put runs on the board this season.
"If my leadoff man can have 50 RBIs and 100 runs at the end of the year, he's going to be very, very productive in our league," Baker said. "Choo's on pace to get that and more."
Entering Sunday with 35 RBIs and 73 runs scored, Choo is on track to drive in just barely more than 50 runs and score a shade under 110. With the limited chances he has had to bring runners home, Choo, who has more home runs than any other leadoff hitter this year, has done well. In 93 plate appearances with runners in scoring position before Sunday, Choo was batting .234 with eight doubles and 19 RBIs, and Baker said his numbers would be even better if he wasn't at the top of the lineup.
"He's one of our best hitters with runners in scoring position," Baker said. "It's just where he's hitting ... because the bottom of the order wasn't getting on for a while. It's better now."
Mesoraco making strides with bat, behind plate
CINCINNATI -- Devin Mesoraco's recent offensive surge, including his first career multi-home run game on Saturday, is what the Reds have expected all along from him at the plate. Behind it, the 25-year-old catcher is still a work in progress.
With Ryan Hanigan on the disabled list since July 11, Mesoraco has handled the majority of the catching duties and taken advantage of the opportunity by batting .333 with four homers and 12 RBIs in his last 15 games, including 12 starts, entering Sunday. But when manager Dusty Baker watches Mesoraco, he's looking at much more than offensive production.
"There's a lot of stuff that goes into being a catcher," Baker said. "It's the toughest position on the field -- mentally and physically. You can't take that strikeout with the bases loaded out on the field, and vice versa, you can't take a bad inning to the plate."
When it comes to catchers, Baker said more often than not a player will excel offensively or defensively, but rarely are they elite in both aspects. However, he hopes Mesoraco, who first played for the Reds in 2011 after being the club's first-round Draft pick in 2007, can be one of the exceptions.
Although he didn't want to compare Mesoraco to anyone specifically, Baker pointed to injured Cardinals backstop Yadier Molina as an example of the progress a catcher can make. Known for his defensive abilities since he broke into the Majors in 2004, Molina gradually improved his bat and was hitting .330 as one of the key pieces in the St. Louis lineup before going on the disabled list at the end of July.
After playing 54 games last season and 18 the year before, Sunday marked Mesoraco's 70th appearance in 2013. Baker said Mesoraco has improved in all facets of the game since last season, but he also expressed the importance of being patient with young catchers.
"It takes a while," Baker said. "And by the time a catcher is 100 percent ready, usually you only get two or three years out of them and they're broken down."
Worth noting
• Ryan Ludwick continued to struggle while on his rehab assignment on Saturday, going 0-for-5 for Triple-A Louisville. In eight rehab appearances, Ludwick entered Sunday going 2-for-24 (.083) while he works his way back from a torn labrum in his right shoulder that he suffered on Opening Day.
Jeremy Warnemuende is an associate reporter for MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.


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>Racing>October "Virtual" race sign-up - 5K, 5Mile, 10K
Roads were made for journeys...
You've got that sub-15 minute guy on the brain, don't you!
I was hoping he might give me some tips!
Please note: a 10 mile division has been added!
If I add an ultramarathon division you gonna go run that this weekend?


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25.0150 Definitions.Cite as [A.S.A.C. § 25.0150]
For the purpose of this article the following definitions shall apply:
(a) "Abattoir" means any slaughtering or meat processing, meat canning, curing, smoking, salting, rendering, or other similar establishment.
(b) "Meat" means the edible part of the muscle of cattle, sheep, swine, or goats which is skeletal or which is found in the tongue, in the diaphragm, in the heart, or in the esophagus, with or without the accompanying or overlying fat, and the portions of bone, skin, sinew, nerve, and blood vessels which normally accompany the muscle tissue and which are not separated from it in the process of dressing. "Meat" also includes fish, other seafoods, fowl, or game.
(c) "Meat food products" means any articles of food or any article intended for or capable of being used as human food which is derived or prepared, in whole or in substantial and definite part, from any portion of any cattle, sheep, swine, fish, other seafoods, fowl, game, or goat.
(d) "Offal" means the inedible portions of animals or poultry handled in the abattoir. This includes tankage from rendering tanks, hair, bones, paunch contents, manure, and similar material.History: Pub. Health Reg. 5, eff 23 Sep 64 § 1.


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Jewell Passes Lie Detector Test
ATLANTA: Richard Jewell, the security guard under investigation for the bombing at Centennial Olympic Park, has passed a lie detector test but remains under FBI suspicion. The test was administered by Dick Rackleff, a former FBI agent now in private practice, who said in a press conference Tuesday that there was no doubt in his mind that Jewell had no knowledge about the bomb. "Jewell's attorneys are growing more and more smug and their rhetoric is getting stronger," says TIME's Greg Fulton. "The FBI continues to say that they are waiting for additional forensic results. But they have been saying that for the past week." Meanwhile, Jewell continues to be the object of media scrutiny and finds himself a virtual prisoner in his own house while his attorneys furiously file motions to get his property returned to him and to gain possession of FBI affidavits taken from people at the scene. For now, Jewell remains in limbo. "We just wish these jerks up there would get off their butts and tell the truth," G. Watson Bryant, Jewell's original attorney, told Fulton after the press conference as he pointed toward the local FBI offices. The truth, says Fulton, is that the FBI has proved unwilling to lift the spotlight off Jewell with no other suspects in hand. -->


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In Reply to: What we may not see! posted by Tim on November 07, 1999 at 03:19:07:
: All should read this Please take the time It could save you from a life time of misery, "ASPARTAME /marketed as 'Nutra-Sweet', Equal, and Spoonful. In the keynote address by the EPA, they announced that there was an epidemic of multiple sclerosis and systemic lupus, and they did not understand what toxin was causing this to be rampant across the United States. When the temperature of Aspartame exceeds 86 degrees F, the wood alcohol in ASPARTAME converts to formaldehyde witch turns into formic acid, which in turn causes metabolic acidosis. ( this form of acid is the poison found in the sting of fire ants). The methanol toxicity mimics multiple sclerosis; thus people were being diagnosed with having multiple Sclerosis in error. The multiple sclerosis is not a death sentence. In the case of systemic lupus, they are finding it has become almost as rampant as multiple sclerosis, especially in Diet Coke and Diet Pepsi drinkers. Also, with methanol toxicity, the victims usually drink three to four 12 oz. Cans of them per day, some even more In the cases of systemic lupus, which is triggered by ASPARTAME, the victim usually does not know that the aspartame is the culprit. The victim continues its use, aggravating the lupus to such a degree, that sometimes it becomes life threatening. When they got people off the aspartame, those with systemic lupus usually become asymptotic. On the other hand, in the case of those diagnosed with Multiple Sclerosis, (when in reality the disease is methanol toxicity), most of the symptoms disappear. They have seen cases where their vision has returned and even their hearing has returned. This also applies to cases of tinnitus. "If you are using ASPARTAME (Nutra-Sweet, Equal, Spoonful, etc.), and you suffer from fibromyalgia symptoms, spasms, shooting pains, numbness in your legs, cramps, vertigo, dizziness, headaches, tinnitus, joint pain, depression, anxiety attacks, slurred speech, blurred vision, or memory loss you probably have ASPARTAME DISEASE!" There were Congressional Hearings in which aspartame was included in 100 different products. Since this initial hearing, there have been two subsequent hearings, but to no avail. Nothing as been done. The drug and chemical lobbies have very deep pockets. Now there are over 5,000 products containing the chemical, and the PATENT HAS EXPIRED! At the time of this first Hearing, people were going blind. The methanol in the aspartame converts to formaldehyde in the retina of the eye. Formaldehyde is grouped in the same class of drugs as cyanide and arsenic--DEADLY POISONS! Unfortunately, it just takes longer to quietly kill, but it is killing people and causing all kinds of neurological problems. Aspartame changes the brain's chemistry. It is the reason for severe seizures. This drug changes the dopamine level in the brain. Imagine what this drug does to patients suffering from Parkinson's Disease. This drug also causes Birth Defects. There is absolutely no reason to take this product. It is NOT A DIET PRODUCT! The Congressional record said, "It makes you crave carbohydrates and will make you FAT". A Dr. Roberts state's that when he got patients off aspartame, their average weight loss was 19 pounds per person. The formaldehyde stores in the fat cells, particularly in the hips and thighs. Aspartame is especially deadly for diabetics. All physicians know what wood alcohol will do to a diabetic. We find that physicians believe that they have patients with retinopathy, when in fact, it is caused by the aspartame. The aspartame keeps the blood sugar level out of control, causing many patients to go into a coma. Unfortunately, many have died. People were telling us at the Conference of the American College of Physicians, that they had relatives that switched from saccharin to an aspartame product and how that relative had eventually gone into coma. Their physicians could not get the blood sugar levels under control. Thus, the patients suffered acute memory loss and eventually coma and death. Memory loss is due to the fact that aspartic acid and phenylalanine are neuro-toxins without the other amino acids found in protein. Thus it goes past the blood brain barrier and deteriorates the neurons of the brain. Dr. Russell Blaylock, neurosurgeon, said, "The ingredients stimulates the neurons of the brain to death, causing brain damage of varying degrees Dr.Blaylock has written a book entitled "EXCITOTOXINS: THE TASTE THAT KILLS" (Health Press 1-800-643-2665). Dr. H.J. Roberts, diabetes specialist and world expert on aspartame poisoning, has also written a book entitled "DEFENSE AGAINST ALZHEIMER'S DISEASE"(1-800-814-9800). Dr. Roberts tells how aspartame poisoning is escalating Alzheimer's Disease, and indeed it is. As the hospice nurse told me, women are being admitted at 30 years of age with Alzheimer's Disease Dr. Blaylock and Dr. Roberts will be writing a position paper on some case histories and will post it on the Internet. According to the Conference of the American College of Physicians, they are talking about a plague of neurological diseases caused by this deadly poison". Dr. Roberts realizes what was happening when aspartame was first marketed. He said, "his diabetic patients presented memory loss, confusion, and severe vision loss". At the Conference of the American College of Physicians, doctors admitted that they did not know. They had wondered why seizures were rampant (the phenylalanine in aspartame breaks down,: The seizure threshold and depletes serotonin, which causes manic depression, panic attacks, rage and violence) This poison is now available in 90 PLUS countries worldwide. Fortunately, Print this Article out and warn everyone you know. Take anything that contains Aspartame back to the store. Take the "NO ASPARTAME TEST" and send me your results. I assure you that MONSANTO, the creator of Aspartame knows how deadly this is. They fund the American Diabetes Association, American Dietetic Association, Congress, and the Conference of the American College of Physicians. The New York Times, on November 15, 1996, ran an article on how the American Dietetic Association takes money from the food industry to endorse their products. Therefore, they can not criticize any additives or tell about their link to MONSANTO. How bad is it. There Are 92 documented symptoms of aspartame, from coma to death. The Majority of them are all Neurological, because the aspartame destroys the Nervous system. Aspartame Disease is partially the cause to what is behind some of the mystery of the Dessert Storm health problems. The burning tongue and other problems discussed in over 60 cases can be directly related to the consumption of an aspartame product. Several thousand pallets of diet drinks were shipped to the Dessert Storm troops.(Remember heat can liberate the methanol from the aspartame at 86 Degrees F ). Diet drinks sat in the 120-degree F. Arabian sun for weeks at a time on pallets. The service men and woman drank them all day long. All of their symptoms are identical to aspartame poisoning. Dr. Roberts Says "consuming aspartame at the time of conception can cause birth defects". The phenylalanine concentrates in the placenta, causing mental retardation, according to Dr. Louis Elias, Pediatrician Professor Genetics, at Emory University in his testimony before Congress. In the original lab tests, animals developed brain tumors (phenylalanine breaks down into DXP, a brain tumor agent) a neurosurgeon, said, " when they remove brain tumors, they have found high levels of aspartame in them". Stevia a sweet food, NOT AN ADDITIVE, which helps in the metabolism of sugar could be ideal for diabetics, has now been approved as a dietary supplement by the FDA. For years, the FDA has outlawed this sweet food because of their loyalty to MONSANTO. If it says "SUGAR FREE" on the label-- DO NOT EVEN THINK ABOUT IT! Senator Howard Hetzenbaum wrote a bill that would have warned all infants, pregnant mothers and children of the dangers of aspartame. The bill would have also institute independent studies on the problems existing in the population (seizures, changes in brain chemistry, changes in neurological and behavioral symptoms). The powerful drug and chemical lobbies killed it. Letting loose the hundreds of disease and death on an unsuspecting public. We hope to have the help of some world leaders. Again, please help us too. There are a lot of people out there who must be warned, please let them know this information. Take a look at what you are doing that maybe killing you. What is 4 weeks try a natural diet. it could be a life time of joy. I'd bet on you. Timfxd I am so grateful that you posted this!
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2013 Spring Issue 4 (May 3, 2013)
Men's Track and Field Victorious at Rolex Classic Against All Odds
While the Carleton College men's track and field team won only two of the 17 events in this year's Rolex Classic against St. Olaf College, the Knights claimed victory in the meet. As a tradition, at the end of the day, the teams pick a random event. The school that won that event wins the meet.
Men's Tennis Defeats St. Thomas to Claim First Round Bye in Playoffs
The Carleton College men's tennis team closed the regular season with a 7-2 triumph over the University of St. Thomas in a matchup of regionally-ranked squads. The victory locked up the No. 2 seed and the coveted first-round bye for the upcoming MIAC Playoffs. This is the 11th consecutive season that the Knights have posted a top-2 finish in the conference standings.
Softball Splits Hamline Doubleheader, Prepares for MIAC Playoffs
Kaitlin Bagley '14 had five hits on the day, and Keelin Davis '16 tossed another gem as the Carleton College softball team split its third straight doubleheader. Host Hamline University prevailed in game one, 5-3, but Davis recorded her first collegiate shutout, 2-0, in the nightcap.
Women's Tennis Defeats St. Olaf as Claire Spencer Posts Top Win Total in MIAC
Claire Spencer '16 won her seventh consecutive singles match and closed the MIAC regular season with an unblemished 10-0 record in conference contests as the Carleton College women's tennis team defeated St. Olaf College by a 7-2 margin. The match was moved to the Owatonna Tennis Center due to wet weather.
Baseball Sweeps Bethel
Jeff Dsida '14 set the tone today for the Carleton College baseball squad (12-14, 2-8 MIAC), homering to straightaway centerfield on the first pitch of the Knights' first turn at bat. Carleton went on to sweep the Bethel University Royals (19-10, 6-6 MIAC) by scores of 5-4 and 8-4 to pick up their first conference victories of the season.


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http://mmajunkie.com A new door opened, at least in theory, to Strikeforce fighters this past week when ex-UFC champ Frank Mir was exported to fight Daniel Cormier in October.
While Cormier's engagement is frequently billed as the last in the Strikeforce heavyweight division before being folded, the man he defeated to win the promotion's heavyweight grand prix title also is owed a fight.
That man, Josh Barnett (31-6 MMA, 2-1 SF), is one of the more marketable fighters in the division despite a recent loss to Cormier. As quick with submissions as he is in interviews, he would be a welcome addition to the UFC.
But at this point, he is far from being physically ready to get in any cage. More than two months after breaking his hand in the first round against Cormier, he could get a timeline for when he'll be ready to hit things, and by extension, plan for his final Strikeforce bout, when he visits a specialist on Friday.
Mentally, he's already there.
"They need somebody who saw me lose the fight last time and is maybe a little more bold and a little more brave," Barnett told MMAjunkie.com (www.mmajunkie.com). "Please. Please make that mistake. I like getting paid for your lack of judgment."
In May, Barnett was unanimously outpointed by Cormier in a fight that left them battered and bloodied as it drew praise – Cormier for his craft and power, and Barnett for his toughness. Cormier also injured his hand, but elected for a quicker turnaround against Mir.
Having felt firsthand the power and talent of Cormier, Barnett is sure the former Olympian's current run won't be stopped.
"I think 'DC' takes him out within two rounds," he said. "He's such a tough, physical, well-conditioned and just smart fighter. I think Frank is coming off a loss, and I don't think that his style matches up that well with 'DC.'
"Frank has got that X-factor in his submission game. But I think 'DC' is one of the top four fighters in the world right now."
At this point, Strikeforce parent Zuffa hasn't indicated whether Mir's crossover is a one-time deal. While it appears that other UFC fighters could follow, it's just as possible that new talent will be signed to meet Barnett. Officially, Cormier is the only other heavyweight on its roster.
Barnett presumably has until March to fulfill his obligations. That's when a one-year broadcast deal between Zuffa and Showtime expires, though that timeframe could be extended if the two companies extend the relationship.
It's not in Barnett's character to plead for anything in his career or life, so he's fine with whoever is put in front of him.
"Line 'em up," he said. "It doesn't really make a difference who shows up, they've all got to go."
There are a few opponents he would like more than others, of course – Antonio Rodrigo Nogueira, for example. While the Brazilian veteran is currently on the mend from a broken arm issued by Mir at UFC 140, Barnett would happily welcome him back.
"I would love that," he said. "That is a fight I would absolutely love. I don't see that happening, especially now that he's got to get his plate removed. But please, bring it. I want to put a nail in the coffin of that whole trilogy."
Then there's Tim Sylvia, who came within a hair of fighting Cormier. Barnett considers him a friend, but would fight as a professional.
And there's Junior Dos Santos, who's a pipe dream in his current career state, but nonetheless a strong one.
"I could beat him the next fight out, I could beat him three fights out," Barnett said. "I know that I have everything that's necessary to beat Junior. I could fight him on the feet. I'm already better on the ground than he is. You've got to take a guy out of his comfort zone."
It's academic, however, until health is no longer keeping him from his job. Barnett expects he'll cross over to the UFC once his time with Strikeforce is done, but nothing is certain, and his old beef with Zuffa brass can't be discounted when it comes to how negotiations could play out.
But he could give them an awfully good reason to pick him up by making the best of his remaining fight.
"I think every MMA promotion in the world needs a guy like me," Barnett said. "The UFC needs people that can not only fight, but also be able to capture the audience's attention and expand that market.
Nobody can fill that void like I do."
For more on the UFC and Strikeforce's upcoming schedules, stay tuned to the Rumors section of the site.


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The System Sonogram
Mocking The Draft
Prospect Profiles
Vital Signs 4-26-2017 Offensive Trends
Tim Huwe
Wednesday, April 26, 2017
Justin Wilson Agrees To 4.25 for 2018 1-12-2018
Justin Wilson wasn't very good last season with the Cubs. 2018 is his chance for redemption, with a new pitching coach. His 2018 salary has been determined at $4.25 million. With Wilson's struggles went Chris Bosio's chances to stick around. Bosio hadn't had a reclamation project of note in a few years. Some of the prospects didn't seem comfortable with him in charge. With thos in mind, moving on from Bosio to Jim Hickey made sense. Poaching pitching guru Jim Benedict from the tire fire that is
There Are Two Kinds Of People.... 1-8-2018
Two types of people are deniers that MLB is leaning toward becoming a de-facto salary cap league. Many are at the mumble-mumble stage, which I'll get to, as well. The more teams that are under-playing fielding the best team possible in a competitive season, the more likely MLB is a salary cap league. What is the mumble-mumble stage? Imagine you are working at a facility. You have an idea for an improvement. It's a new idea, or something that has been mentioned a few times. You bring the idea
Finding Advantages In The System 1-11-2018
I've been "in the process of writing this one" for awhile. It starts, then fizzles. It makes sense, then it meanders. The Cubs made a trio of promotions today that cleared up something obvious. The team wants to stay ahead of the down markers. This is a football reference. If a football team wants to be successful, they are well served by doing well on first down. Facing 3rd and 2 instead of 3rd and 16 doesn't guarantee a victory, but the path seems a bit easier with shorter down and distance
Rivera Rolls To Anaheim 1-10-2017
I should be upset. I was hoping Rene Rivera would be the borderline ideal back-up catcher for the 2018 Cubs. I'm not upset. Quite the opposite. I'm completely good with how the Rivera story has played out, and it might get better still. Part of the reason the Cubs recent success has been so enjoyable is that so many of the players have the basic grasp of humanity. From Anthony Rizzo and Kris Bryant, to Willson Contreras and a backfield of prospects, this Cubs system is rather easy to cheer
Cubs Prospect Profile- Keegan Thompson 12-26-2017
My look at Keegan Thompson as a Cubs prospect is as much a look at decision-making as anything else. Thompson was selected by the Cubs in the third round of the June 2017 Draft. From Auburn University, Thompson had a WHIP of below one in his college career in the Southeastern Conference. As such, there's not much of a reason to "hold him back" in April. If healthy, Thompson makes as much sense as anyone as a rotation starter in South Bend. While Alex Lange makes more sense as a starter, the
Cubs Prospect Profile- Corey Black 1-8-2018
Remember Corey Black? He was the piece the Cubs added from the Yankees back in 2013. Whether you like what he's done or not, the acquisition, and Black's time with the Cubs, deserve another look. A 2012 4th Round Yankees selection (Faulkner University in Montgomery, Alabama), Black found his stride with the Cubs. In five post-trade starts with Daytona, Black won four of them. Those Cubs won the championship that year. Black advanced to Tennessee the next season, and had a reasonably decent
My Top 14 Names For 24 In June 1-8-2018
Whether you want to admit it or not, the Cubs recent success has been largely based on "guessing right" in the draft and international venues. Kris Bryant. Willson Contreras. Even Gleyber Torres and Eloy Jimenez have chipped in to appearances in the League Championship Series. With MLB free agents seemingly needing an act of Congress to sign three-year deals, I'm minding prospects more this off-season. Both internal and external prospects. Here is a look at my current Top 14 for the Cubs at pick
Cubs Prospect Profile- Alex Lange
Back in the Tom Baker-era, an entire Doctor Who season run was based on gathering pieces of a scavenger hunt called The Key To Time. I won't give any spoilers, but fans of the timelord were riveted on whether the Doctor could collect all the pieces. Whether the Cubs can internally develop their own pitching is the key to an extended run, beyond 2021. Today's discussion is on 2017 first-round choice Alex Lange. Lange, as long as he's a Cubs piece, will be linked to Dexter Fowler. Fowler was the
2018 Cubs Draft- Joey Bart 1-6-2017
A look at my top fourteen college baseball prospects is a tell to me which games I should follow. While the current pecking order is different from the order that will be likely in June, the Cubs are likely to take a college player. Skim off the first five options, and I should develop opinions and preferences regarding the next nine or ten. As Georgia Tech catcher Joey Bart falls in this range, he's worth a look. Here's my draft look at the Yellow Jackets Bart. Before I go any further, I'll
eddy julio martinez
gleyber torres
jonathan herrera
corey black
jeffrey baez
kenta maeda
zack greinke
james shields
chris archer
ryan williams
trey mcnutt
eddy martinez
jen-ho tseng
pj higgins
taylor davis
adrian morejon
lazarito armenteros
az phil
edgar olmos
christian villanueva
john lackey


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The $8.7 million Lakeside Credit Union of Oak Creek, Wis., has merged with the $1.4 billion Educators Credit Union in Racine, Wis.
This is Educators CU's second acquisition deal since Jan. 1, 2012, when it merged with the former $11 million Kyle Central Credit Union in South Milwaukee.
Although Lakeside CU's net worth was 22% in 2012, its loan income dropped from $365,727 in 2009 to $260,669 in 2012, according to NCUA financial performance reports. In the same time period, Lakeside CU's investment income fell from $34,479 to $11,382, and its fee income decreased from $84,189 to $71,150. What's more, the credit union's membership declined from 2,108 in 2011 to 1,778 in 2012, according to data from Callahan and Associates Inc.
The merger became effective this month. Lakeside CU's Oak Creek branch remains open. The credit union's five employees are now working for Educators CU, including former president/CEO Wendy Heberling, who is the Oak Creek branch manager.
"Educators' (115,000) members have been asking for a branch in that area for a while," said Robert Walleser, senior vice president of branch operations at Educators. "We are happy to welcome the member-owners of Lakeside to the Educators Credit Union family."


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One day as a youth in his native New York City, Jay Hieron had finally had enough of being picked on.
"I was going into high school, and I was like 'I'm done with this. It's time to grow up and turn into a man,'" Hieron recently told MMAjunkie.com Radio (www.mmajunkie.com/radio). "I took action. I went to the boxing gym with my sister's boyfriend at the time. .. Then I joined my (high school) wrestling team.
"I was fascinated by it. It was crazy. I fell in love with the sport. That's what got me through high school. That's what got me to this point today. That step I took in my life."
The bullies didn't automatically quit picking on the fresh-dressed Hieron, but word of mouth quickly spread after a group tried to jump him for his jacket a little while after he took up wrestling.
"He started grabbing me, and I hit a duck under and suplexed him," Hieron said. "Even his boys were shocked. That was it. Nobody ever messed with me again. Then I became real successful in my high school wrestling, and everyone knew I could wrestle. It was cool after that.
"People prey on the weak. Sometimes you have to stand up for yourself. I don't condone violence, but if dudes are messing with you all the time, there comes a time where you put your foot down."
After putting his foot down after he felt he got jobbed during a close decision loss to Bellator welterweight championship Ben Askren in October October, Hieron (22-5) said he's moved on. He returns at Friday's Legacy Fighting Championship 12 event against Brazilian veteran Romario Da Silva (19-9-1). The bout takes place at Houston's Arena Theater and airs on AXS TV (formerly HDNet).
"It was just time for me to move on," said Hieron, a UFC and Strikeforce veteran who left Bellator following the narrow loss that snapped his 10-fight win streak — which included his victorious run through Bellator's season-four welterweight tourney. "It was a good opportunity. I got in there and did what I did.
"I felt I won the title, but the judges didn't see it that way. Everybody in the world that watched it knows I did, but it didn't pan out the way I wanted to, so it was just my time to move on."
Hieron was originally scheduled to make his Legacy debut against LFC welterweight titleholder Mike Bronzoulis, but an injury this past week forced him off Friday's card.
No matter the opponent or promotion, the 35-year-old Hieron said he's happy to still be participating in the sport he picked up after his wrestling days ended prematurely at Hofstra University, where he tested positive for marijuana prior to his senior season.
"I don't carry those weights around with me," he said. "I let that go along time ago.
"I got a fight next week, so I'm happy."
Obviously Hieron — whose very first fight in the UFC came against welterweight champion Georges St-Pierre at UFC 48 — would love to work his way back into the world's top MMA promotion, but he said that will happen in due time.
"Right now I'm not thinking about that," he said. "I got a fight next weekend, and I'm still in the game. I'm doing what I love to do at the end of the day. I have to have a positive mind frame. It will happen one day. Right now I'm focused on my job, and that's Legacy Fighting on Friday, July 13."
In the end, Hieron said, everyone loves a comeback story.
"What I look up to is not the guy with a perfect record, but the guy who has to go do something in his career, who has to come back from a loss – when the chips are stacked against him and he comes back and puts it all on the line," he said. "There are so many fighters like that I look up to. Those are the kind of fighters and people I like because that's kind of my story. I'm attracted to that."
For more on Legacy Fighting Championships 12, stay tuned to the MMA Rumors section of the site.
MMAjunkie.com Radio broadcasts Monday-Friday at noon ET (9 a.m. PT) live from Mandalay Bay Resort & Casino's Race & Sports Book. The show is hosted by "Gorgeous" George Garcia, MMAjunkie.com lead staff reporter John Morgan and producer Brian "Goze" Garcia. For more information or to download past episodes, go to www.mmajunkie.com/radio.


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Global Pursuits: SJU Inspires Tara Nolan '11MBA
From Italy to New York, young alumna Tara Nolan '11MBA has pursued her dreams, and she's quick to point out the role St. John's played in getting her where she is.
"Having decided the global route was for me, it only made sense to study for an international degree at an institution with an international state of mind, and St. John's offered me that," explained Nolan, who currently works as Associate Director of Marketing and Communications at PHD Worldwide, a global media and communications agency. For Nolan, St. John's is a family affair, as her mother – Patricia Nolan '07G – is also a graduate and serves as Director of Development, College of Pharmacy and Allied Health Professions, in the University's Office of Development.
"I knew that St. John's would provide me a base of fellow alumni," Nolan added, "and a tight-knit community at my disposal, which made the whole experience feel very connected."
While pursuing her M.B.A. at St. John's University's Rome campus, she traveled across Europe with her roommates and friends and came across a unique business called Cabin Charter, which would eventually lead to one of Nolan's proudest creations.
"Cabin charter was an innovative type of travel," said Nolan. "It allowed you the flexibility to book your own space on board a vessel and enjoy the exclusive feeling of having your own boat, cruising around with others in really amazing places."
Using this idea as a base, Nolan wrote her very own business plan after graduation and created IntersailClub, a vacation-planning service that arranges sailing experiences all across the world.
"Without having gone to Rome to gain the business acumen I received at St. John's," she said, "and partake in the European lifestyle I had at my disposal, there is no way IntersailClub would have ever materialized. St. John's gave me the power to create."
Meanwhile, Nolan has been making her mark at phd, working to ensure that the company's brand is consistent and helping to develop long-term strategic initiatives. And, of course, she remains connected and committed to St. John's, supporting the University whenever possible and always encouraging fellow alumni to reach out to her on LinkedIn or on Twitter @tknolan.
"St. John's attracts a variety of interesting people that end up going on to do great things," she said. "We have a wide-spanning global network, so it would be hard not to want to stay connected to all of that!"
Join Nolan in staying connected to St. John's and support the University today.


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Munroe Regional Medical Center officials weighing competing offers to lease the medical center to national hospital chains debated Monday whether the additional $63 million being offered by one of the companies should be a major factor in their decision.
Munroe Regional Medical Center officials weighing competing offers to lease the medical center to national hospital chains debated Monday whether the additional $63 million being offered by one of the companies should be a major factor in their decision.
Shands/Health Management Associates and Duke LifePoint both want to lease Marion County's 421-bed, non-profit facility. HMA is offering $200 million and an additional $200 million to make improvements to the facility. Duke LifePoint is offering $138.7 million, with a similar $200 million commitment for improvements.
Munroe's Strategic Options Work Group — comprised of doctors, administrators and hospital board members charged with investigating possible lease deals — met Monday to discuss their findings after visiting HMA and Duke LifePoint hospitals in recent weeks. The group visited HMA-owned Wuesthoff Medical Center-Rockledge in Florida and Duke University Medical Center in Durham and LifePoint's Danville Regional Medical Center in Danville, Va.
Munroe officials will visit two more hospitals this week.
The discussion Monday centered on the question of quality care versus money.
Work Group member Dr. Harvey Taub said that one issue to consider was each company's business culture, its compatibility with Munroe, and other hospitals they already have in Florida with which Munroe could collaborate and work.
Although LifePoint owns or leases nearly 60 hospitals in 20 states, its only Florida hospital is the relatively small Putnam Community Medical Center in Palatka.
HMA already owns or operates 22 hospitals throughout Florida.
But Taub said it looks as if Munroe has demonstrated a longer commitment to quality care than HMA.
He said HMA has recently incorporated corporate-wide quality control measures while Munroe has had a quality control officer in its ranks for the past 16 years.
Another issue that Munroe representatives are debating is their relationship with Shands at the University of Florida.
Under the HMA/Shands partnership, Shands would offer specialized and expert advice involving Munroe's patient care.
Some Munroe doctors complained that Shands has a history of competing in Marion County and poaching Munroe patients.
They also claim that Shands often won't accept their patients who need advanced care if the patients don't have good insurance or can't pay.
HMA and Shands may have addressed that concern in a meeting with Munroe doctors and administrators last week.
Steve Purves, Munroe president and CEO, said that during the meeting Shands agreed to accept any patients referred by Munroe doctors, regardless of their ability to pay. Purves said Shands offered to put the agreement in writing.
That meeting was not open to the public because only one Work Group member attended. If two had attended and discussed issues likely to be before the Work Group for a vote, it would have been open to the public, Hospital District trustee lawyer John Dean said Monday.
But Taub was skeptical.
"How do you ignore 10 to 15 years of a poor relationship?" he asked.
In response, Purves said one thing is certain: "If they're not in collaboration with us, they'll be in competition with us."
Meanwhile, Duke LifePoint oversees the day-to-day operations of its hospitals and makes necessary capital improvements. Duke oversees the clinical standards and helps its hospitals offer new services.
Work Group members said that between HMA and Duke LifePoint, HMA was more business oriented while Duke LifePoint touted its clinical orientation.
"The (Duke LifePoint) conversation was safety, safety, safety, while at (HMA) it is a little different," trustee Chairman Jon Kurtz said. "Whether it's worth $63 million, (that's the question)."
Munroe is owned by the state-sanctioned Marion County Hospital District and is overseen by seven trustees who are appointed by the County Commission.
The trustees lease the hospital to Munroe Regional Health System Inc., which is overseen by a 13-member board, some of whose members also are district trustees.
Without property tax support — a ballot measure failed in November — Munroe leadership says it must lease the hospital to a separate company to invest and keep the hospital competitive.
Once trustees lease the hospital, they plan to oversee the lease payment, using it to fund community health issues and initiatives.
Trustee Joe Hanratty said he's convinced that either Shands/HMA or Duke LifePoint could adequately operate Munroe, but "it's hard to ignore the $63 million question."
Trustee David Cope said he was just as concerned that whoever leases the hospital maintain the facility during the entire length of the lease and not stop making improvements as the lease nears its end.
The more money either of the two health care companies are willing to commit on the front end of the lease contract, the more likely they are to maintain the facility, Cope said. But Cope warned that 40 years was a long time and much could change about Munroe's health care market.
Ponder and Company executive Dave Atchison, hired by Munroe to oversee the lease process, said that although he understood concerns about how HMA or LifePoint might operate Munroe, both companies understood the value of protecting their reputations.
But Taub also pointed out that HMA typically purchases hospitals in financial trouble and that Munroe isn't in that situation yet.
"When leasing ... it's more than just the purchase price," Taub said.
Which of the two would be the best "strategic partner? Which is going to share our vision moving forward?" he asked.
But trustee Larry Strack said the richer offer by HMA suggests that HMA thinks more highly of Munroe's potential.
Contact Fred Hiers at 867-4157 or firstname.lastname@example.com.


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News & Events
For the Media
A Place for Everything and Everything in Its Place at Clarkson University Science Cafe April 6
[A photograph for media use is available at http://www.clarkson.edu/news/photos/lbrehm.jpg .]
"A Place for Everything and Everything in its Place" is the topic of a discussion by SUNY Potsdam Physics Professor Larry Brehm at the next Science Cafe at La Casbah, 6 Elm Street in Potsdam, on Wednesday, April 6, at 7:15 p.m.
There are nearly 100 chemical elements that make up everything around us. But how are they arranged into solid molecular forms?
Answers begin more than 150 years ago, with a political hothead Frenchman who developed a type of mathematics called group theory and then got himself killed in a duel.
His new math, which seemed useless initially, gave us new ways to look at shapes in space and is of fundamental importance in the development of methods for the determination of molecular structures, many of which, DNA for example, have profound significance for us today.
Join Brehm as he sheds light on this fascinating chapter of science history and its far-reaching, present-day consequences.
Science Cafes bring together engineers, scientists and townspeople in a relaxed, informal setting, such as coffeehouses and pubs. The speaker makes a short presentation about a topic in his or her field, and then opens up the floor to discussion.
Find out more about Clarkson's Science Cafe at http://www.clarkson.edu/sciencecafe.
E-mail Daniel ben-Avraham at firstname.lastname@example.com with any questions or suggestions for future Science Cafe topics.
Clarkson University launches leaders into the global economy. One in six alumni already leads as a CEO, VP or equivalent senior executive of a company. Located just outside the Adirondack Park in Potsdam, N.Y., Clarkson is a nationally recognized research university for undergraduates with select graduate programs in signature areas of academic excellence directed toward the world's pressing issues. Through 50 rigorous programs of study in engineering, business, arts, sciences and health sciences, the entire learning-living community spans boundaries across disciplines, nations and cultures to build powers of observation, challenge the status quo, and connect discovery and engineering innovation with enterprise.


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Bulldogs heading to finals at UVM
For the Banner
BRATTLEBORO -- The Brattleboro Colonels had the goal of getting to the state championship from the beginning of the season.
But in early December, Brattleboro coach Eric Libardoni's team knew it was easier said than done.
On Friday night, the No.2 Colonels dropped a nail-biter, falling to No. 3 Burr and Burton Academy, 2-1, in the Lake Division semifinal.
With 4:59 remaining in the second period, Elijah Brown proved to have the game winner from the point, eventually sending the Bulldogs (17-3-1) to the Vermont state championship for the first time since 2009.
With traffic in his face, Brattleboro (18-4) goalie Greg DiSilva had almost no chance to detect the puck and missed it glove side.
The defensive breakdowns in front of DiSilva carried from game to game this season and that trend would come to haunt the Colonels in their most important game to date, with each Bulldogs goal resulting from traffic upfront and screens.
Just 22 seconds into the game, they gave up a slap shot goal to put Brattleboro into an early 1-0 hole.
But the Colonels didn't give up easy and at the end of the first period, senior Jimmy Podlaski tied it with a wrist shot past BBA senior goalie Zack Stewart.
"I thought we played really well. That's a good team, and well coached. They've got some good players. Their goaltender was excellent, and that was the difference. We couldn't get anything by him," Libardoni said. "[DiSilva] played well too, but they had two screen goals, and we couldn't get one to go by [Stewart]. He played great. Give him all the credit."
BBA will face U-32, a 6-2 winner over Northfield in the other Lake Division semifinal, on Wednesday night at 6:30 p.m. at Gutterson Fieldhouse on the campus at UVM.
If you'd like to leave a comment (or a tip or a question) about this story with the editors, please email us. We also welcome letters to the editor for publication; you can do that by filling out our letters form and submitting it to the newsroom.


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I spotted this on my front door this morning. I live in the South West. It is quite small and doesn't appear to be furry like a bee. Does anyone know what it is?
I think it is a House fly that has been infected by the fungus Entomophthora mucae.
Hope that is of interest.
Hi I am sure Jen is absolutely correct,fascinating picture with the white bands of the fungus so clearly marked.This is presumably where the fungus is either entering or exiting through the segments of the body?
Yuk! That's put me right off my supper!
Thank-you both though. Really interesting information.


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* Refer to Bulletin 3193 for purification conditions. ** For example, Profinity GST Resin is available only in prepacked cartridges. ***Profinity eXact Purification Resin.
Affi-Gel 102 support is for use with 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDAC) carbodiimide coupling reagent, which immobilizes ligands that contain primary or terminal carboxyl groups. This support offers flexible alternative chemistries and economy.
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[[A new type of game ?]]6 years since the release of the phenomenal Warcraft: Orcs and Humans, the Blizzard is set to strike again sometime by the end of 2000, with Warcraft III.
Blizzard Entertainment has announced that this highly anticipated game would deviate from the current trend of Real-Time Strategy to one of, what they call, 3D Role-Playing Strategy, or RPS.
Expected to be nothing less than revolutionary, RPS makes it possible for the player to focus attention on smaller and more critical issues such as commanding small squads of elite units and their quests in the intriguing 3D world of Azeroth, rather than being burdened with resource management and the assembling of massive armies of expendable units.
[[New features]]
Hence, the player is exposed to unprecedented levels of interaction and flexibility. RPS also attempts to recognize the players tact and strategic abilities more than in Warcraft II, which focused more on resource management and army sizes.
But for those who fear for the future of strategy games the way they used to be fret not! The resource management and army assembling duties still very much a part of your game!
In addition to RPS, Warcraft III incorporates many innovative features. Players would have the option of choosing between 6 unique races, rather than 2, as in the previous Warcraft. Blizzard announced that 3 of these would be Humans, Orcs and Demons, but remained tight-lipped on what to expect for the others.
Warcraft III will also allow for greater fluidity in 3D animations, increased flexibility for customization of your world, and a wider variety of multiplayer options such as Team Play over Blizzard's internet gaming service, www.battle.net.
Now over a year in development the longest time for any Blizzard game, and loaded with out-of-the-ordinary features, Warcraft III will be too tempting to overlook this holiday season!


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'Happy Endings' Recap: Friendship… It Will Kill Us All
The functional social circle — the gang of confidants whose group mentality is based on constructive interaction and healthy barriers. For many of us, the phenomenon is nothing more than an urban legend, as we instead revel in the glory of whatever manifestations of codependence, passive-aggression, competitiveness, and any number of other vices are upheld by the people with whom we choose to pass the time. Marginal toxicity began pervading small screen cliques some time ago, overtaking the spotlit posses of Cheers, Taxi, and The Mary Tyler Moore Show, subtly. Seinfeld kicked this up a few dozen notches, allowing the likes of other '90s and post-millennium wonders to grab hold. But no television program has been more deliberately devoted to the delivery of the theme than Friends.
Often cited as a precedent and spirit animal for our contemporary gem Happy Endings, Friends not only showcased but brazenly celebrated the diametric self-obsession maintained from the pilot through the series finale by the West Village sextet. One particular exhibition of the group's ill regard for the world beyond the confines of their personal circumference transpires in a Season 6 episode, "The One with Rachel's Sister." Upon a hearing a knock on Monica's apartment door, the entire gang is visibly bewildered as they try to fathom who, if not any of them, could possibly be paying a visit. This sort of insistent oblivion to all other living entities is the theme ventured in this week's Happy Endings, and to a much more extensive degree.
Happy Endings has consistently been a much more self-aware program than its mega-hit predecessor. Calling attention to its own retcons, abuse of sitcom staples, and other absurdities, the show is no stranger to meta commentary. But this week's application might be the most extensive yet, as the very idea that these Chicago-set adult-children are so desperately invested in their definition as a component of this irrevocably adhered six-headed monster, a malignant societal pockmark, is, and always has been, the life blood of the program. So in the latest "The Ex Factor," Happy Endings doesn't just put its latest device under a microscope, it really challenges its entire state of being. And it does so with comedic brilliance.
Penny is flustered when her boyfriend Pete (hey, Nick Zano is still on the show!) invites her to hang out with his friends for a change. After struggling to understand the very concept of such an idea, Penny agrees, diving headfirst into the disaster that is destined to be: a conversation with normal, mature, mentally stable adults. In fact, each of the three storylines on this week's episode involve the interloping of outsiders in the Happy Endings group. First, Max, along with Alex and Dave, tries to track down his totally awesome new roommate (Mark-Paul Gosselaar! It's Mark-Paul Gosselaar, everybody!) after he doesn't return home one night: Dave plays a surprisingly adroit detective on the hunt for the well-dressed Chase, calling his credit card company and tracing his steps (all while wearing Chase's swanky jacket), while Max and Alex crawl around on couches and practice "card tricks."
Jane invites her former lover, a woman named Ryan, to dinner at her apartment. Brad, initially delighted to learn that Jane's ex is female (employing the usual creepy behavior that sitcom males exhibit in the presence of lesbians), becomes infuriated with jealousy and insecurity when Ryan reveals that Jane once told her that she loved her. In turn, Brad invites one of his ex-girlfriends over (and she comes right away — she must have been doing, like, nothing), inflating the situation with scathing tension and hostility.
In other words, not quite healthy adult behavior coming from any of the described parties. But this is the norm for this crew, as divulged by Penny in her description of what she considers average behavior. Wacky high jinks, misunderstandings elevated to catastrophe, deception, manipulation, one-upsmanship. Week after week, these are the ideals this group upholds, practicing in the vein of Friends, Three's Company, and the like. And even when presented with the alternative — the opportunity for normalcy, as represented here by Pete's cronies — the central gang turns to their regular debacles. Because, as Penny's boyfriend comes to realize at the end of the episode, that's far more interesting. And this is TV.
So while the rest of us embedded in toxic friend groups might suffer consistently at the hands of our horrid social choices, those on scripted comedies rejoice: things generally work out for these self-destructive loons. Because, again, this is TV. But to all those real life individuals who relate a little too well to the Happy Endings group, maybe it's time to distance yourself from your own manifestations of roommate stalking, spouse sparring, and insult pile-ons. Join a book club or something.
[Photo Credit: Danny Feld/ABC (2)]
10 Bitchiest One-Liners From This Week's Don't Trust the B—- in Apt. 23
'Pretty Little Liars' Recap: Who Did Start the Fire? We Find Out!
The Least Normal Things About 'The New Normal': Mr. Mom Edition
Craziest Celebrity Swimsuits (Celebuzz)


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I've owned one of these since last christmas, I've owned a lot of basses and this one is by far my favourite of the bunch. Upon first putting it on I noticed it was a bit smaller than most other basses I've played but the sustain on it was still as amazing if not better than the rest.
The neck is a bit chunky but equally fast and the higher frets are easily accessed with the contours around the neck/body joint. The EMG-SSD pickups give a nice punchy sound with a little more midrange than standard EMG pickups.
This bass is an entry level Spector model and while I have compared this to higher end Spectors, this bass definitely lives up to its name, it certainly is a Performer! Unlike the higher end Spectors, the edges of the bass are not curved which makes it feel chunky and a bit less ergonomic than say a Euro series or NS but you get what you pay for, which is a high quality instrument.
I'd recommend it to players of any skill level and I hope mine stays with me for years to come, so far over the past year its served me well and hasn't let me down once!


text: This is a web-based course offered through OnCourse. 3 cr hrs. Class Number 11958 Second Summer. A survey of the law governing labor-management relations. Topics include the legal framework of collective bargaining, problems in the administration and enforcement of agreements, and protection of individual employee rights. Instructor: Michael Nicholson, DLS, IUPUI.


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Ran out of my favorite Mrs. Miller's Cherry Jelly so I went for a 103 mile late afternoon ride to resupply. The only place I know that stocks this jelly is the Baltic Mill, Baltic, Ohio. They still grind their own flours of all types at this mill. If you want a 50# bag of oatmeal they will make it up for you.
I let my GPS guide me on beautiful curvy hilly roads in the heart of Ohio Amish country. Some of the high hill views across the farms and woods were outstanding. Most of the ride was in Holmes County. Lots of road apples. Lots of buggies and and Amish men and women walking and riding home from work on bicycles.
Just as I before entering the village of Charm, I got caught in a pop up heavy rain. No safe place to pull over and suit up so I kept going. Rain mostly let up after 10 minutes, but I was pretty soaked...stock windshield on a K1200RS does not give much protection.
Shortly after going through Farmerstown, I encountered two Amish men driving a heard of 20-30 dairy cows down the two lane road...no shoulders, just ditches. No where to go so I moved to the side to let them pass. All was fine until a bull tried to mount a cow less than 20' in front of me. The cow just kept moving, so he was not successful. The bull gave me the evil eye but decided his girlfriend was more interesting and I was not a threat, so he followed her down the road.
After the herd passed, I rode to the Baltic Mill and was starting to dry out by the time I got there. Bought my jelly...they had a unusually good inventory so I stocked up. The clerk wrapped the jars in newspaper so they would not break in my saddlebag. We talked for a few minutes and I headed out.
Could see the dark clouds were still to the north so I took the southern route home...not as quite as much fun, but still a curvy road that mostly follows the river valleys. Pulled in to my garage just as the rain started rolling in.
It was a beautiful relaxing ride!


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We haven't done this since 2008 because of the 007, and it's a fantastic exchange so I can't wait to do it again! I love it because it makes it feel like summer even when it's freezing cold here and I'm trying to stay warm under piles of blankets. Damn you northern hemispherians Your stories do not have to be specifically summer-related, feel free to request whatever you wish!
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text:
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|Symptoms related to wearing more clothing (failing to uncloth)
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they should put that money into updating their GNSS kit. The System 500 that the surveyor is using is over 10 years old and practically obsolete now (it cannot handle the GLONASS constellation or SV32).
Surveyors for Ordnance Survey maps have taken to Twitter to help the public understand what they are doing, with a Twittermap of the UK plotting their thoughts and observations as they roam the country, looking at roads and measuring things. The OS Mastermap receives 5,000 changes every day, as houses are taken down, roads are …
they should put that money into updating their GNSS kit. The System 500 that the surveyor is using is over 10 years old and practically obsolete now (it cannot handle the GLONASS constellation or SV32).
It's a well-tested bit of kit that does the job needed. Seems unnecessary to update...?
OS_Dom appears to be a Ninja. Ditto OS_Matt.
That's nearly an inch! That doesn't even sound like the OS's level of accuracy from the days before GPS.
Clearly you've never dealt with surveyors ...
Look, Surveyors used to be able to say here's a property stake and give a rough approximation. They they can take more accurate measurements between that stake and another stake using lasers.
However, in terms of finding your X,Y,Z coordinates the best you can do is only within a couple of cm. (that would be slightly more than an inch.)
There's a couple of factors, ranging from clock synchronization, accuracy of all clocks, atmospheric interference, and use of a radio signal from a known geographic point and how accurate its position is known. (Also its clock accuracy and synchronization to yours. )
So really a couple of cm is 'state of the art'.
And this is assuming that we're talking about being in an open field and have clear reception. When you go into an urban environment, you will lose accuracy. (Note there are ways to compensate...)
Why should the landlord give them information for free, that they'll then sell back to him?
It's well past time the OS data was made freely available. There are all sorts of useful things that could be done with computerised access to top-quality mapping. The original maps were made using tax funding, and councils have to give them free information. Why are they still charging?
If you want a map go and buy one. Don't ask me to subsidise you. I've got enought to pay for with all these illegal wars, aircraftless aircraft carriers, warplanes that are built to be mothballed, subsidising middle-class people to buy the latest resource eating green gizmo and paying Fred Goodwins pension.
Do you mean _this_ free data? https://www.ordnancesurvey.co.uk/opendatadownload/products.html
Then what about all the European INSPIRE data? And all the geographic data the UK government has made available through INSPIRE? You too could run a query to find all the comprehensive schools with greater than 1000 pupils within 1 mile of an A Road with a 6 in its number, and get the name and address of its headteacher.
Oh, then of course, there's the Vector District Raster, where the OS has kindly rendered its vector data with standard OS cartographic styling, not to mention the smaller-scale stuff.
OK, I grant you its not direct access to Mastermap, but all the data (apart from some of the legacy stuff like Landform) there is derived from Mastermap. OS Vector District is more than adequate for GIS needs, if you want greater detail, survey it yourself or buy it. You won't find that sort of quality in the US, TIGER is in a shocking state (being surveyed by individual census areas, with limited quality control), and has only just made it into OpenStreetMap due partly to the problems integrating it with existing (and sometimes more accurate and up-to-date) OSM data.
May I kindly suggest you look up the concept of the past tense.
That sounds impressive, and yet there is still an imaginary made-up road running through my garden that has never been there (Before my house was built, everything was a field with no roads within 1/2 mile).
I don't mind the imaginary road too much (it's better than imaginary numbers!), but it was a bit of a headache when I tried to sell my house!
That'll probably be one of their deliberate mistakes they put in to track who is nicking their data and selling it on for profit...
They met a man headed for his own back door carrying a shotgun. Perhaps he'd just been shooting.
Not pointing it at them or anything. Some exaggeration there perhaps.
(Maybe he was keeping down the pigeons who were eating the corn that goes to make our bread. Or maybe he just bought the land so he could go shooting on it...)
"There was no reply so they tried to go round the back of the house and met the landlord approaching with a shotgun."
They knew it was the *Ordnance* survey when they signed up. What's the problem?
I'm assuming that's accurate to a couple of CM on the ground, as opposed to a couple of CM on the map?
Waiting for the first joke about "pundits"
"How satisfied are you with the performance of your local priest over the last year?"
Actually the modern OS GPS sticks have sub-millimeter precision using OS' own radio broadcast network of around 85 high frequency stations from known positions.
Just read some of the tweets on the website - crap. Just like all other tweets really
The Dickheads should know better.
They have all of our data so why be stupidly visible?
Shotguns don't fire bullets, Reg. They fire shells.
Shotguns fire pellets
Similar to Grapeshot.
Airguns fire pellets.
Shotguns - amazingly - fire Shot.
they _use_ shells to fire a bunch of pellets which are indeed called 'shot'. or they can also fire a sodding big bullet-y thing called a 'slug'. everyone happy now?
so we were all sort of right except el reg, which was utterly wrong, as bullets aren't involved at any point in the shotgun process...