text:
Our old campus!
Our new campus!
T. J. Austin Elementary School was originally located on 3.37 acres at the corner of North Moore and West Franklin Streets in Tyler and received its first pupils in September, 1936. The brick building had only six classrooms when first constructed, but before the year ended growth made it necessary to add two classrooms. An auditorium and two more classrooms were completed in 1941; three classrooms and a modern cafeteria were added in 1947; and four more classrooms came in 1951. November 1963 saw the addition of seven new classrooms, a library, restrooms, and storage space. Continued growth led eventually to the inclusion of several portable buildings. After 70 years, in 2007, a beautiful new school building on the same site replaced the original structures. (See map.)
The school was named for Thomas Jessie Austin, the principal of Emmett J. Scott School. Mr. Austin, a scholarly Fisk University graduate, came to Tyler from Brownsville, Tennessee. This tall, quiet educator was strong and courageous in his convictions and emphasized the importance of character, self-respect, and industry to his students. Mr. Austin served as a member of the Board of Stewards for St. James CME Church for 20 years and as a Sunday-school teacher for 44 years. He was also president of the Westview Cemetery Association. At the age of 92 he was presented with the coveted Silver Beaver Award by the Boy Scouts of America for outstanding service. Mr. Austin died in 1959.
Mamie Griffin was the first principal, serving from 1936 to 1955.
L. P. Tolbert was Austin's second principal, from 1955 to 1960.
James W. Anderson served in that capacity from 1960 to 1973.
Charles E. Mathis was principal from 1973-1984.
Gladys Johnson served as principal from 1984-1995. After Mrs. Johnson retired, she served as TISD School Board Member from 1998-2005.
Malcolm Gipson served as principal from 1995-1999.
Carolyn Turner served as principal from 1999-2012.
Walter S. Perez served as principal from 2012-2016.
Brandy Holland, served as principal, 2016-2020.
Joshua Currie, our current principal, began his tenure the 2020-2021 school year.


text:
Hello! Welcome back to the blog. Today I have something special to share with you; a freebie for my digital/printable 'Hot Right Now' collection. I try to do these with all of my collections so people have the option to try out my collections before possibly purchasing them. Whenever I design my collections, I always end up with a lot of pieces I don't end up using. Most of the time I will include (some) of these in my freebie pack so that people who may have already bought the collection can also get a use out of it.
This is my biggest freebie pack to date (and mostly filled with exclusives!) so I hope that you will enjoy it.
This freebie pack contains:*
- 12 Exclusive 12″x12″ Papers
- 2 Printable A4 sheets with ephemera – 49 pcs (+exclusives)
- 2 Printable A4 sheets with 4″x6″ journaling cards (exclusive)
You can download this freebie pack here.
If you like the collection and want to purchase the full collection from my Etsy shop, you can purchase it here and get a 35% discount with the code FREEBIEHRN35 (this applies to all orders, so you can also use it on getting another collection if you wish to do so). The code will be valid until June 25th.
* You are free to use this freebie pack for personal use, please contact me if you want to use it for commercial purposes.
I hope you will enjoy this freebie pack!

subset: commoncrawl


text:
Now that Disney Plus is out in the wild for US, Canadian, and Netherlands residents, is it worth the $6.99 a month price? Our Disney Plus first impressions show that it is a huge treasure trove of classic Disney content. There's plenty for Marvel and Star Wars fans to like, too.
Here's a quick first look at Disney Plus, which is based on a few hours of watching movies and TV shows on the service. We used the browser version, along with the Android and Roku apps.
We are aware that for now, some Disney Plus users are currently experiencing login and streaming issues. This was expected, but hopefully these launch day issues will be fixed later today. We will update this post when we have more information.
Order Disney Plus
Disney Plus: Content
If you are not a Disney fan, Disney Plus is not going to be your cup of tea. However, if you are, there's a ton of content to dive into. Yes, that includes the very first Mickey Mouse short film, Steamboat Willie, which was released way back in 1928. In between, you can stream tons of classic and current Disney animated feature films and shorts, live-action films, and shows. A large majority of the Marvel Cinematic Universe movies are available. Nearly all of the Star Wars and Pixar movies can be streamed. If you love documentaries, there's also a host of National Geographic movies and series to stream as well.
One thing we will mention is that there are a few movies and TV shows from 20th Century Fox on Disney Plus. That's due to Disney buying the library of TV shows and movies from that studio in 2018. You can stream the entire library of episodes from The Simpsons, for instance. It also has a few family-friendly movies from Fox, like The Sound of Music and Avatar. We wish Disney Plus had more Fox content — the Ice Age movies would be a perfect fit. Marvel fans would love to see the X-Men and Fantastic Four movies on Disney Plus, too.
See also: Disney Plus vs Netflix: Which should you choose?
The exclusive new content is understandably going to be sparse at first. The shows are also geared mostly for a younger audience. Only the Star Wars series The Mandalorian targets an older demographic. One criticism of Disney Plus at this stage is there is not enough content that will appeal to a more mature audience. We know that's part of the design of Disney Plus, but we think there's some wiggle room to add more movies and shows for older audiences, particularly from the Fox library.
User interface
The UI of Disney Plus is very clean, with colorful images serving as menu and content selections for the Roku and web-based apps. We like the fact that the search page also includes "collections" of various Disney Plus content. Hopefully these will be useful for subscribers who want to dive into, say, all the Toy Story content on the service immediately. You can also just click on top to check out all of the movies and shows at once.
The Android app has a similar UI, with a couple of differences. One is that you can download movies and shows to your device. There's an icon at the bottom that shows which Disney Plus content you have downloaded. You can change the download video quality settings to standard, medium, or high. Obviously, the higher the quality, the more storage space it will take up on your device. Of course, you can set up your own profile, with a ton of great icons available to choose from the vast Disney library of characters.
Other Disney Plus features
We love the fact that there is a wide variety of platforms available for Disney Plus at launch. That includes game consoles like the Xbox One and the PlayStation 4 (although, sadly, not the Nintendo Switch). One word of warning: We have seen some reports that Disney Plus won't work on the Chrome browser with Chromebooks.
We like that Disney Plus supports 4K resolution and HDR for a number of its movies and shows. That includes its Marvel movies, and, for the first time ever, the classic and prequel Star Wars film trilogies. We also like that the service has a variety of audio and subtitles for its content. You will need download speeds of at least 25Mbps for 4K content and 5Mbps for 1080p streaming
Overall, our Disney Plus first impressions are quite positive. If you are the audience for this kind of content, we think it will be well worth your $6.99 a month. Of course, there are ways to also get Disney Plus for free. We wish it was available in more parts of the world at launch. However, we also know that there are licensing issues that unfortunately have to be dealt with before Disney Plus expands to more territories.
Next: The full list of Disney Plus movies and TV shows
If you have tried out the service, what are your Disney Plus first impressions? Do you like it, or is it not for you?


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Surgical management of hereditary colorectal cancer: surgery based on molecular analysis and family history
Manejo quirúrgico del cáncer colorrectal hereditario: cirugía basadas en el análisis molecular y los antecedentes familiares
J. Perea, I. Justo, E. Álvaro, M. Lomas, J. Díaz Tasende1, J. C. Marín1, A. Franco1, F. Colina2,3, Y. Rodríguez2, J. Martínez4, L. Robles5, M. Urioste6 and M. Hidalgo
Departments of General Surgery B, 1Gastroenterology, 2Pathology, 3Tumor Registry, 4Molecular Biology Unit, 5Genetic Counsel Unit. Department of Oncology. "12 de Octubre" University Hospital. Madrid, Spain. 6Human Genetics Group. Spanish National Cancer Research Center. Madrid, Spain
The importance of colorectal cancer (CRC) is increasing. A proportion show a hereditary component, as in Lynch syndrome and Familial Adenomatous Polyposis, and a recently defined entity as well, namely, Familial Colorectal Cancer type X. The high probability to develop CRC in these groups may, at the time of recognition, change surgical management, including its timing or even the surgical technique. In some cases prophylactic surgery can play an important role. The possibility of using tools that allow recognition of the aforementioned syndromes, including microsatellite instability, immunohistochemistry for DNA mismatch repair system proteins, and especially their mutations, is on the basis of therapeutic strategies that differ from those employed in sporadic CRC cases.
Key words: Colorectal cancer. Surgery. Lynch syndrome. Familial adenomatous polyposis. Familial colorectal cancer type X.
The incidence of colorectal cancer (CRC) is very high nowadays. Data from the Spanish Health Ministry show that 25,665 new cases were diagnosed in 2003 (1). It is estimated that 20% of patients with CRC have familial aggregation, and around 5% of all cases are hereditary.
CRC with a hereditary component includes Lynch syndrome, or hereditary non-polyposis colorectal cancer (HNPCC), which is also the most common form, and familial adenomatous polyposis (FAP), with two phenotypes, classic and attenuated.
In the last few years a possible new hereditary form of CRC has been defined, called familial colorectal cancer type X. This form meets the Amsterdam criteria for Lynch syndrome, but from a molecular point of view does not follow the same oncogenetic pathway, characterized by the presence of microsatellite instability (MSI) (2-4).
Each of these groups carries some degree of increased risk for CRC development, very high in Lynch syndrome and FAP, and not very well defined in familial CRC type X. Each group needs a different management strategy not only during follow-up, but also regarding the possibility of chemoprevention and of prophylactic surgery to prevent the development of a primary CRC or a metachronic neoplasm. The risk of CRC in FAP is 100% (5), so prophylactic surgery is a necessity in this case. In other forms, as Lynch syndrome, surgery is considered once the CRC is diagnosed because the cumulative risk of metachronic CRC through the age of 60 is nearly 35% (6); notwithstanding this, the risk for a first CRC is 75% (7), depending on multiple factors such as the altered gene and type of mutation. In the other familial forms, in which the risk of developing a CRC remains unknown, the role of prophylactic surgery is yet to be defined, taking into account the major criteria defined by You et al. (8) when addressing prophylactic surgery: presence of genetic tests that allow identification of mutation carriers; a high penetrance associated with the mutation; an effective surgical technique to reduce the risk with tolerable morbidity; an affordable loss of organ function; and the possibility to assess that the patient remains disease-free during follow-up.]]> The aim of this work is to underline the importance of this group of patients with hereditary syndromes or with CRC aggregation. Their identification may change surgical management: namely, surgical timing as well as the technique performed, and establish the role of prophylactic surgery. We will try to gain some insight into its molecular basis, and also into the possibility of its application to clinical practice.
Material and methods
We present three cases that show the three types of familial CRC. The first and the third ones, examples of Lynch syndrome and FAP, have a defined hereditary component and a clear genetic basis. The remaining one is a potential case of familial CRC type X. In each one, molecular determinations were carried out to determine whether they belong to one of the known syndromes. Surgical management was based on the results of these molecular measurements.
Case 1
A 40-year-old female was diagnosed with CRC of the right colon and evaluated at the High Risk CRC Unit in our institution because of her familial cancer history. Her medical history only showed some plastic surgery procedures for a traumatic lesion, and her familial cancer history fulfilled Amsterdam criteria type I (Fig. 1). Diagnostic colonoscopy showed an ulcerated neoplasm in the right colon; two polyps of the left colon were resected at the same exploration. Staging workup was without findings. Biopsy of the neoplasm confirmed the diagnosis of CRC; the resected polyps were tubular adenomas, without evidence of dysplasia. Immunochemistry showed an absent expression of Msh2 and Msh6 Mismatch Repair System (MMR).
]]> Due to the clinical suspicion of Lynch syndrome, and after obtaining the informed consent, a subtotal colectomy was carried out. The pathology report was of a well-differentiated, mucinous colorectal adenocarcinoma infiltrating pericolic fat, with 28 lymph nodes free of disease, stage B2 (Astler-Coller modified classification). The postoperative course was uneventful and the patient was discharged in good condition. Genetic testing showed a pathogenetic mutation in MSH2 (c.467 G > T, exon 9) thus confirming the diagnosis of Lynch syndrome. This mutation causes a stop signal and a truncated protein. The patient was referred to the Genetic Counsel Unit.
Case 2
A 42-year-old male presented with microcytic and hypochromic anemia. His only previous disease was hepatic cysts. His family cancer history showed that his father was diagnosed with CRC at the age of 64, and a paternal aunt had died from ovarian cancer at the age of 60 (Fig. 2). A colonoscopy and upper digestive endoscopy were carried out, in which a malignant neoplasm at the hepatic flexure of the colon was found and biopsied. Upper endoscopy showed a dysfunctional hiatus with chronic esophagitis. Biopsy of the neoplasm showed colorectal adenocarcinoma. The microsatellite technique was carried out in biopsy samples, and showed stability for all five microsatellites in the Bethesda panel (9), although the familial pedigree fulfils Amsterdam II criteria. Staging showed no metastatic spread.
The patient underwent right hemicolectomy. A pathological study of the surgical specimen showed a mucinous, poorly differentiated, adenocarcinoma infiltrating perivisceral fat, with 21 lymph nodes free of disease (stage B2; pT3N0M0). Immunohistochemical testing for MMR proteins was carried out, which showed a normal expression of Mlh1, Msh2, and Msh6.
Case 3
A 28-year-old female with a family history of FAP was evaluated at the High Risk CRC Unit of our institution. She was asymptomatic, without any personal history of disease. Her family history is summarized in figure 3. A diagnostic colonoscopy was carried out in which more than 100 polyps were found along the whole length of the large bowel. Biopsies from some of them were reported as adenomatous polyps without dysplasia in any of them. She is the youngest affected member in the family, and that is the reason why a genetic analysis was carried out in her. A mutation in the APC gene was detected (exon 7, c.268 G > T) that generated a stop signal and a truncated protein. Due to these clinical and molecular findings, she is waiting for prophylactic surgery, in which a panproctocolectomy with ileal pouch-anal anastomosis will be carried out.
]]> Discussion
Lynch syndrome
Lynch syndrome is the most common form of hereditary CRC, and is characterized by the development of CRC, endometrial cancer, and other malignancies at an early age. It is due to a germline mutation in one of the DNA mismatch repair genes (mismatch repair genes, MMR): MLH1, MSH2, MSH6 and PMS2. An alteration in one of these genes causes an accumulation of multiple errors in DNA repetitive sequences (microsatellites) along the genome. This finding is known as microsatellite instability (MSI), and is frequent but not exclusive in Lynch syndrome.
Surgical management
Once a CRC is diagnosed in a patient with Lynch syndrome a complete colonoscopy must be carried out in the first place, due to the high risk for a synchronous tumor. The elective surgical technique must take into account the risk of metachronous CRC during follow-up, which in some studies is as high as 16% at 10 years (10). For this reason subtotal colectomy with ileorectal anastomosis is recommended at the time CRC is diagnosed. According to the study by de Vos tot Nederveen Cappel WH et al. (11), if this operation is carried out at an early age (younger than 47 years) life expectancy is increased by 2.3 years. In this study data are not adjusted for quality of life, but the authors suggest that this should be increased as well, because the need of follow-up colonoscopies is reduced and so is concern about developing a new neoplasm. Our patient with Lynch syndrome (case 1) was in a follow-up program because of his family history of cancer. Although a genetic study was not performed before surgery for CRC, the possibility of Lynch syndrome could be assumed on the basis of absent Msh2 and Msh6 protein expression on immunohistochemistry testing, together with clinical suspicion (Amsterdam I family). Surgery was indicated on these grounds. It is controversial whether this type of surgery should be indicated without previous genetic testing. We think that, if the patient has given a fully informed consent, and with immunohistochemistry testing for MMR system proteins or MSI, it can be an acceptable indication, provided that the frequency of CRC in the family is high enough.
In healthy carriers of Lynch syndrome mutations some facts are to be considered when facing the possibility of indicating prophylactic surgery. The first one is that an effective and low-risk examination technique, namely colonoscopy, is widely available. Secondly, incomplete penetrance for CRC in this syndrome is as high as 70-80% (12). Lastly, according to recently published data, the risk of developing CRC decreases in older patients (13). For these reasons prophylactic colectomy should not be considered the operation of choice in this group of patients.
Prospective studies should be carried out to determine more precisely the cumulative risks at different ages, and on that basis to define the role of prophylactic surgery for healthy carriers who could benefit from it.
In the prevention of gynecological neoplasia some studies recommend that total hysterectomy with double anexectomy be carried out simultaneously with surgery for CRC (14) in patients with Lynch syndrome, but there are some families whose Lynch syndrome phenotype shows only CRC, and no other neoplasm. In these patients the indication for such operation is not as clear-cut, especially during their fertile period, as happened in our case.
Familial colorectal cancer type X syndrome
In the last few years a group of patients has been identified with a family tree that fulfils clinical criteria for Lynch syndrome, but that does not show the molecular features related to MMR system genes, as MSI and lack of expression of MMR proteins in the tumors (2-4). In this type X syndrome age at diagnosis of CRC is higher, CRC location is mainly in the left colon and rectum, and the proportion of mucinous tumors is smaller, and all features in contrast to Lynch syndrome. The family oncologic pedigree would be almost restricted to CRC. As a recently defined entity, there are no studies identifying its molecular basis, nor follow-up studies to assess the risk of metachronous CRC development, which seems to be smaller than in Lynch syndrome (3,15,16).]]> Surgical management
The lack of follow-up data in this group of patients underlines the fact that standard oncologic surgery is indicated instead of any kind of prophylactic operation. That is why, in case 2, although Amsterdam II criteria for Lynch syndrome were met, and particularly the fact that the patient showed an early-onset CRC, immunohistochemistry testing and the absence of MSI determined that standard, and not prophylactic surgery, was carried out.
Familial adenomatous polyposis
Familial adenomatous polyposis (FAP) is an autosomic dominant syndrome defined by the presence of more than a hundred colonic adenomatous polyps, mostly developing at a young age. The risk of malignant transformation is 100%. FAP represents less than 1% of all CRCs. Patients can develop polyps at any level of the digestive tract, with the duodenum being the most frequent location (17). Extraintestinal features, such as desmoid tumors, congenital hypertrophy of the pigmented retinal epithelium, thyroid neoplasia, hepatoblastoma, and brain tumors can also be found (18).
Surgical management
It is clear that carrying such a high risk of CRC development there is no discussing the need for prophylactic surgery in FAP (19), with some debate arising about which operation should be carried out. FAP patients without CRC found in any polyps, but in whom malignancy cannot be ruled out, must undergo prophylactic surgery. So it was indicated in our case (case 3), from the clinical, as well as the molecular and family history points of view.
The three available techniques are: panproctocolectomy with permanent ileostomy (PPCI); total colectomy (TC) with ileorectal anastomosis; and panproctocolectomy with ileoanal pouch (PPCR). The election of a particular technique depends on the desired quality of life after surgery and the need of follow-up for the risk of malignancy in the rectal remnant (19,20). PPCI is rarely the first option because of the consequences of permanent ileostomy, even if this is the technique with fewer surgical complications (21). Only technical considerations (short small bowel mesentery due to desmoid tumor) or sphincter muscle dysfunction determine the indication of this technique.
PPCR is preferred to TC due to a lesser risk of developing CRC in the rectal remnant, though this risk is not completely eliminated (23). CRC can develop not only in the pouch but in the anal transition area (24). The follow-up strategy depends on the operation performed. When a pouch is made endoscopy should be carried out every 2 to 5 years, while with TC the interval between explorations should be of 6 months. A temporary diverting ileostomy can be made to prevent anastomotic leakage when a pouch is used. Although PPCR is the preferred technique, controversy still exists regarding several technical aspects, such as transanal mucosectomy with sutured or stapled anastomosis, indications for laparoscopic access, a lesser than total mesorectal excision to prevent nerve damage, and in some cases to avoid temporary ileostomy (23).
Though it is clear that prophylactic surgery is the treatment of choice for FAP, there are certain circumstances in which delaying surgery can be considered, especially when there is a high risk of developing a desmoid tumor, which often grows on surgical scars. The use of chemopreventive agents such as COX-2 inhibitors should neither delay nor be substituted for surgical treatment.
]]> Conclusions
As can be seen from the examples presented, especially in hereditary cases, the high risk of CRC, as in FAP, or of developing a metachronous tumor, does change surgical indications in this group of patients with CRC. For this reason it is important that the need to carry out tests as indicated in each case be underscored so that patients carrying a higher risk can be preoperatively identified in order to perform the best surgical technique. Nowadays, when clinical characteristics, associated cancer risks, and the molecular basis of family aggregation for CRC are unknown, surgical indications and techniques should remain as in standard cases, although an individualization of subjects and their families is mandatory. Essential criteria to be considered include age at diagnosis of CRC and family cancer history, as well as characteristic phenotypes, as in FAP. In the next few years, with the identification of the facts behind genetic susceptibility in CRC aggregations, prophylactic surgery will find a more important role than it currently has.
1. La situación del cáncer en España. Madrid: Ministerio de Sanidad y Consumo; 2005. [ Links ]
2. Lindor NM, Rabe K, Petersen GM, Haile R, Casey G, Baron J, et al. Lower cancer incidence in Amsterdam-I criteria families without mismatch repair deficiency: familial colorectal cancer type X. JAMA 2005; 293: 1979-85. [ Links ]
3. Valle L, Perea J, Carbonell P, Fernández V, Dotor AM, Benítez J, et al. Clinicopathological and pedigree differences in Amsterdam I-positive hereditary nonpolyposis colorectal cancer families according to tumor microsatellite instability status. J Clin Oncol 2007; 25(7): 781-6. [ Links ]
4. Llor X, Pons E, Xicola RM, Castells A, Alenda C, Piñol V, et al. Differential features of colorectal cancers fulfilling Amsterdam criteria without involvement of the mutator pathway. Clin Cancer Res 2005; 11: 7304-10. [ Links ]
5. Galiatsatos P, Foulkes WD. Familial adenomatous polyposis. Am J Gastroenterol 2006; 101(2): 385-98. [ Links ]
6. Mecklin JP, Aarnio M, Läärä E, Kairaluoma MV, Pylvänäinen K, Peltomäki P, et al. Development of colorectal tumors in colonoscopic surveillance in Lynch syndrome. Gastroenterology 2007; 133(4): 1093-8. [ Links ]
7. Vasen HF, Möslein G, Alonso A, Bernstein I, Bertario L, Blanco I, et al. Guidelines for the clinical management of Lynch syndrome (hereditary non-polyposis cancer). J Med Genet 2007; 44(6): 353-62. [ Links ]
8. You YN, Lakhani VT, Wells SA Jr. The role of prophylactic surgery in cancer prevention. World J Surg 2007; 31(3): 450-64. [ Links ]
9. Boland CR, Thibodeau SN, Hamilton SR, Sidransky D, Eshleman JR, Burt RW, et al. A National Cancer Institute Workshop on Microsatellite Instability for cancer detection and familial predisposition: development of international criteria for the determination of microsatellite instability in colorectal cancer. Cancer Res 1998; 58(22): 5248-57. [ Links ]
10. De Vos tot Nederveen Cappel WH, Nagengast FM, Griffioen G, Menko FH, Taal BG, Kleibeuker JH, et al. Surveillance for hereditary nonpolyposis colorectal cancer: a long term study on 114 families. Dis Colon Rectum 2002; 45: 1588-94. [ Links ]
11. De Vos tot Nederveen Cappel WH, Buskens E, van Duijvendijk P et al. Decision analysis in the surgical treatment of colorectal cancer due to a mismatch repair gene defect. Gut 2003; 52: 1752-5. [ Links ]
12. Guillem JG, Smith AJ, Calle JP, Ruo. Gastrointestinal polyposis syndromes. Curr Probl Surg 1999; 36(4): 217-323. [ Links ]
13. Jenkins MA, Baglietto L, Dowty JG, Van Vliet CM, Smith L, Mead LJ, et al. Cancer risks for mismatch repair gene mutation carriers: a population-based early onset case-family study. Clin Gastroenterol Hepatol 2006; 4(4): 489-98. [ Links ]
14. Lindor NM, Petersen GM, Hadley DW, Kinney AY, Miesfeldt S, Lu KH, et al. Recommendations for the care of individuals with an inherited predisposition to Lynch syndrome: a systematic review. JAMA 2006; 296(12): 1507-17. [ Links ]
15. Jover R, Castells A. Molecular information defines a new entity of hereditary colorectal cancer. Gastroenterology 2008; 134(3): 888-9. [ Links ]
16. Valle L, Urioste M. Molecular information defines a new entity of hereditary colorectal cancer (Reply). Gastroenterology 2008; 134(3): 889-90. [ Links ]
17. Kashiwagi H, Spigelman AD. Gastroduodenal lesions in familial adenomatous polyposis. Surg Today 2000; 30(8): 675-82. [ Links ]
18. Herráiz M, Muñoz-Navas M. Recognition and management of hereditary colorectal cancer syndromes. Rev Es Enferm Dig 2009; 101(2): 125-32. [ Links ]
19. Cordero Fernández C, Pizarro Moreno A, Garzón Benavides M, García-Lozano R, Belda Laguna O, Sobrino S, et al. Follow-up alter surgical treatment of patients with familial adenomatous polyposis: results in a southern Spanish population. Rev Esp Enferm Dig 2007; 99(8): 440-5. [ Links ]
20. Bixquert M. Adherence to a postoperative follow-up protocol in patients with familial adenomatous polyposis may prevent colorectal cancer development. Rev Es Enferm Dig 2007; 99(8): 433-7. [ Links ]
21. Church J. In which patients do I perform IRA, and why? Fam Cancer 2006; 5: 237-40. [ Links ]
22. Al-Sukhni W, Aronson M, Gallinger S. Hereditary colorectal cancer syndromes: familial adenomatous polyposis and Lynch syndrome. In: Jatoi I, Martin RF, eds. Hereditary Cancer Syndromes. Surg Clin North Am 2008; 88(4): 819-42. [ Links ]
23. Kartheuser A, Stangherlin P, Brandt D, Remue C, Sempoux C. Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited. Fam Cancer 2006; 5(3): 241-60. [ Links ]
José Perea García. ]]> Servicio de Cirugía. Hospital 12 de Octubre.
Avda. de Córdoba, s/n. 28041 Madrid, Spain.
e-mail: email@example.com
Received: 28-01-09.
Accepted: 06-05-09.


text:
Limeburners Single Malt Port Cask
Single Malt
Limeburners // Western Australia, Australia
Limeburners is producing Western Australia's first single malts at the time of writing, and they have been doing a mighty fine job of it. The port cask variant is made with Western Australian barley, is copper pot-distilled then matured in an American ex-bourbon cask. It is finished in an Australian-style port cask. Limeburners are non-chill filtered and have no added caramel-coloring, giving them an authentic taste from a sun-burnt country. Note: This is not sold in the US.
Single MaltDistilled in pot stills from 100% malted barley, produced at one distillery, aged in barrels; if Scotch or Irish, must be aged for at least three years.
Cask Typeex-bourbon & Australian-style port
Tasting Notes
"Fresh orange citrus overtones and spices, cinnamon, cloves and cardamom, the whisky drops into toasted malts, slight acetone notes and reminiscent of grandmother's wine cabinet. Dark plums, raisins and cherry wood bring about the end of a succulent whisky. On the tongue, the whisky is sugary sweet, the orange tones from nose turning prickly and the cinnamon becoming more prevalent. The initial taste is prickly alcohol, dying down to a cloying mouth feel. The finish is long, cloying, with sweet citrus fruits and pear, creamy caramel and honey bring about a marvelous end to the whisky. "


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The Tron Foundation and project is constantly making strides in terms of continual listings of TRX on crypto exchanges and also with sealing partnerships across the globe. The most recent one, between the Tron Foundation and Shift Markets, will make TRX accessible to the vast Forex (FX) markets facilitated by SHIFT. TRX will, in turn, be offered on nine brokers in nine different countries. The first broker to list TRX will be a UK regulated firm followed by J.M Financial based in India.
It was during this announcement by SHIFT on businesswire.com, that something unique was noted with respect to the profile of Justin Sun that was shared together with the news. In the brief introduction of Justin Sun, Businesswire.com mentioned that Justin Sun was the former Chief Representative of Ripple. investigating further on LinkedIn yields similar results when Justin's profile is search.
Then follow us on Google News!
From the years of 2013 to 2016 and before he started Tron, Justin was the Chief Representative and Adviser of Ripple Labs – as it was known then- in the Greater China area. He also served as Ripple Lab's Special Representative and Adviser since 2014.
After reading and confirming the above, it is safe to say that any FUD against Justin Sun has been purely ill-intentioned. If his background at Ripple does not scream legitimacy of his ability to lead TRON to higher heights, then the only other thing is his graduation as the first Millenial Graduate at the Jack Ma co-founded Hupan University.
Long story short, Justin Sun is the right man for the job. Extra evidence of this can be seen by his active involvement in the Tron project. One needs only log in to Twitter and follow him to realize how much information he passes on to his followers in 24 hours. Justin has an impressive 455,000 twitter followers.
The Tron project is currently preparing for the token migration that starts on the 21st and ends on the 24th of June. The Genesis block will then be launched on the 25th of June that has also been declared as Tron's Independence Day by Justin Sun. It seems like the Tron MainNet is on course to decentralizing the internet as envisioned by Justin and the Tron Foundation.
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Hear how the first day of one of the best visual effects festivals in the UK unfolded!
Reading Time
We were thrilled to be invited back to the BFX Festival, which is now running in its seventh year.
With some truly inspirational talk across the first day, we thought we'd run through the highlights.
The Festival was kicked off with a keynote from our friends at Dneg, with Creative Director Paul Franklin helming the keynote. Paul discussed where he gets his creative ideas from, which interesting came from everything including Constructivism art to Andy Warhol, 2000AD comics and films like The Thief of Baghdad.
Next up was ILM's Julian Foddy, giving an interesting insight into Spiderman: Far From Home. Outpost followed on the main stage with our talk from Head of VFX Andy Morley and Head of 3D Maurizio Giglioli pairing up to discuss animation and character performance on the Black Mirror Season 5 episode 'Rachel, Jack and Ashley Too'.
Framestore came next, discussing a different insight into Spiderman: Far From Home, while Jellyfish Pictures took a look at their visual development of drones and aliens for the film Captive State.
Finally, MPC finished day one with a fascinating talk about the character development of The Lion King, showing off how 86 different animals were brought to life!
11 September 2019
The original fantasy series is the first Outpost VFX show led out of our Montréal facility.
19 September 2019
Emily is one of three finalists that have gotten through to the Apprentice of the Year award.


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Dryer Vent Wizard Raises Record Amount for Children's Burn Foundation
DETROIT, MI - (Marketwired - Dec 17, 2014) - Dryer Vent Wizard recently announced that the company's third annual fundraiser for the Children's Burn Foundation (CBF) raised more than $14,000 to benefit the non-profit's programs for children burned in fires.
During National Fire Prevention month in October, DVW's corporate headquarters and franchisees participated in a variety of social media and online challenges to achieve record results.
"We nearly doubled the amount raised during the previous year's fundraiser," said Terry Reuer, DVW CEO. "In addition to helping children burned in fires, this month-long drive allows us to raise awareness about fire safety in communities throughout North America."
Scott Thomas, DVW's director of operations, presented the company's donation to Carol Horvitz, CBF's executive director.
"The funds raised through our partnership with Dryer Vent Wizard help to provide much needed educational, medical and psychological care for children who are burned in fires," said Horvitz. "When you have the opportunity to meet and talk with these children, you truly understand how important it is to teach fire safety at an early age. Dryer Vent Wizard is doing that."
DVW is an international franchise that specializes in dryer vent repair, replacement, alteration, cleaning and maintenance for residential and commercial clients.
It is estimated that poorly maintained or clogged dryer vents are the leading cause of appliance fires, resulting in more than 15,500 dryer fires every year. These are only the reported cases.
About Dryer Vent Wizard
Founded in 2004 and headquartered in Farmington Hills, Mich., Dryer Vent Wizard International services more than 9,000 communities of all sizes throughout the U.S. and Canada and helps raise public awareness about the importance of dryer vent cleaning to prevent dryer fires and save energy. For more information or to schedule an appointment, visit www.DryerVentWizard.com or call 866-498-SAFE (7233) in the U.S. and 866-395-SAFE (7233) in Canada.
SOURCE Dryer Vent Wizard
Media Contacts:
Terry Reuer
Dryer Vent Wizard
586-619-2160, ext. 550
Margaret Blohm, APR
Margaux & Associates, LLC
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Tags: Vice
Jim Brady columnsDeveloping an engaging voice remains one of the most underappreciated changes required for successful local digital transformation.
Want more revenue for local journalism? Develop an engaging voice
January 29, 2020
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MediaShift Podcast 250: James Murdoch to lead Disney?; Vice fires 3 as holiday parties remove booze
December 8, 2017
MediaShift PodcastIn the news this week, a new Freedom House study found that 30 governments around the world had been spreading disinformation online and attacking the media, with 18 elections affected by misinformation online and on social media.
MediaShift Podcast 248: Thirty governments stifling internet freedom; Sexual harassment at Vice
November 17, 2017
Futures Lab UpdateHow does VICE News add film-like aesthetics into their news video?
FL#191: VICE's cinematic approach
April 26, 2017
Distribution: What do you really own? What do you really want?Kari Paul is a personal finance reporter at WSJ's MarketWatch where she covers technology, travel, and culture.
Kari Paul: Brand loyalty as a distribution strategy
March 28, 2017
MediaShift PodcastIn the news this week, Vice finally launches its nightly news program on HBO, which gets mixed reviews. News organizations like CNBC, Fortune and Time drop online polls after the second presidential debate.
MediaShift Podcast 208: 'Vice News Tonight' gets mixed reviews; WSJ goes digital-first again
October 14, 2016
MediaShift PodcastIn the news this week, Facebook fires its news editors and puts the algorithm in charge. (You can guess how that turned out: not very well!)
MediaShift Podcast 204: Facebook's algorithm trends down; Vice mistreats freelancers; Matter's Core
September 2, 2016
MediaShift PodcastIn the news this week, BuzzFeed is splitting into two divisions — news and entertainment — with lots of video in both. Google will be punishing mobile websites that use pop-up ads. And Spotify is trying to negotiate long-term deals with major labels.
MediaShift Podcast 203: BuzzFeed splits into two; Vice and Disney pairing up
August 26, 2016
MediatwitsNBCUniversal has decided to invest $200 million in both BuzzFeed and Vox media. They aren't the only traditional media company looking to court millennials by investing in established new media brands.
Mediatwits 171: Valuations gone wild in media with BuzzFeed, Vox Investments
September 11, 2015
MediatwitsThe NewFronts are the digital publishing world's answer to the Upfronts. If you aren't familiar with the Newfronts, they are an opportunity for publishers to pitch advertisers on the value of their audience and tech platform.
Mediatwits 159: The NewFronts go legit, but will advertisers buy in?
May 8, 2015


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11-8-06: The Morning Report-- Election Edition
Election News:
After Previous Gaffes, Networks Mostly Take Their Time (NYT) The television networks reporting on the results of the midterm elections last night exercised an unusual degree of caution in declaring any shift of power in Congress, apparently chastened by previous miscalculations based on exit poll information.
Election Night Innovation: Our List and Yours (Poynter) We know many of you were fully engaged producing your own coverage, so we pulled together examples of work that's worth a look from all different media, in markets of varying sizes, all across the country.
The No-Win Zone (NYO) Sharp Toothed FoxNews Team has a gloomy night.
New Faces Out Front as Networks Plow Through the Returns (USA Today via Mediabistro) But you don't choose a network on news alone; you also choose an anchor. And if the first rule for anchors is "do no harm," all achieved that basic standard. What distinguishes the three is style — whether you prefer, for example, Williams stentorian approach to Gibson's more conversational tone. The Drip, Drip of Election Poll Leaks (Slate)
Morning News:
Clear Channel Has Outdoor Suitor (WSJ) In a deal that would combine the world's two biggest outdoor advertising companies, France's JCDecaux SA said it would like to buy its larger rival, Clear Channel Outdoor Holdings Inc.
FCC Drops Indecency Charges Against Two Shows (WSJ) Regulators backtracked and dropped indecency charges against two television shows, handing a major victory to networks that had gone to court over worries of higher fines and more-aggressive interpretations of indecency rules.
Vanishing Act for Lost, As It Takes 13 Week Break (NYT) After tonight's episode, only the sixth of the still-young fall television season, ABC will take "Lost" off the air for 13 weeks.
Coming Soon To Your TV--Homemade Videos? (WSJ) Web sites like YouTube have vaulted into the vanguard of Internet entertainment by providing a medium for people to post videos of practically any imaginable activity. Now some of the country's largest telecom operators, including Comcast Corp. and Verizon Communications Inc., are trying to determine if there's a business in putting such videos on television.
The television industry's top news stories, analysis and blogs of the day.
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NurseLink Banner Exchange
Critical Issues and Factors
That Affect Implementation of the Therapeutic Community
Potential Solutions to Maintain the Therapeutic Community
This paper is not for copy, in whole or in part, or for distribution without my express permission. Where permission has been given, please ensure that reference citations to selected passages are given proper recognition.
Healthcare in its continuing evolution has brought about changes to the therapeutic environment in which clients and professional psychiatric nurses interact, operate and function. These changes have been brought about by external and internal influences placed upon the healthcare system.
This paper discusses critical issues and factors that threaten the implementation of principles commonly associated with a therapeutic community. Exploration of solutions to these issues, which can be provided by the professional psychiatric nurse, will be presented.
To discuss critical issues and factors that threaten the implementation of the principles associated with a therapeutic community, an understanding of what constitutes a therapeutic community is necessary.
Descriptions of the therapeutic community using a variety of terms interchangeably have created a blurring of the term. These similar, yet unalike terms offer different connotations when used in varying contexts. In exploring principles commonly associated with a therapeutic community, clarification of the terms becomes evident.
An example of the blurring of terms is illustrated by Jones when indicating that "the idea of a therapeutic environment (and sometimes referred to as therapeutic community, therapeutic milieu or milieu therapy) arose from reactions to the dehumanizing conditions in mental institutions and motivated the move to improve hospitals and to treat clients as distinct individuals with dignity and rights" (1998, p. 3-1). These terms therapeutic community, therapeutic milieu and milieu therapy are interchangeably used to describe a set of conditions present in treatment settings for mental health clients. A more concise definition of a therapeutic community is that of Shives (cited in Jones, 1998) who refers to a therapeutic community as "a special type of milieu or environmental therapy using social and interpersonal interactions in the hospital as therapeutic tools to bring about change in the client by encouraging active participation in treatment". Within this definition, the concept of the client being an active participant in their treatment plan is introduced. This environment as described by Shives (cited in Jones, 1998) is inclusive of a variety of settings such as "the hospital, community, home or a private office of a therapist". Jones notes that "this definition emphasizes that the therapeutic community is: aimed at the restoration of social functioning or, in other words, rehabilitation rather than treatment or containment of the mental disorder, a community of staff and clients, a setting where clients are expected to actively participate in their own treatment and carried out in various settings"(1998, p.3-6).
In order for the existence of such an environment, and for clarification, four principles are noted as being indicative of a therapeutic community. These principles as put forward by Wilmar (cited in Jones, 1998) are:
These four principles are enhanced by three commonly descriptive components. Jones describes these components as "distribution of responsibility and decision making, clarity of the role of members and the leadership of the program and high levels of interaction between staff and clients" (1998, p.3-7).
Having clarified the meaning and principles of a therapeutic community, the next section examines critical issues, which can affect implementation of the therapeutic community.
This section examines critical issues affecting the implementation of the therapeutic community. Jones (1998) noted that eight critical factors could affect the therapeutic community. These factors are financial, deinstitutionalization, treatment, the unit team, staff morale, therapeutic community factors and treatment models. Each issue will be explored separately.
The last several years has seen dramatic change in the structure of the healthcare system in British Columbia. This structural change, known as New Directions in Healthcare has regionalized healthcare services. Regionalization of health services attempts to provide geographically drawn communities with health services that meet the needs of the community. The provincial government in the form of block funding provides funding for these services. An appointed Regional Health Board (RHB) oversees the provision of those services. The RHB determines the financial allocation of resources to meet health needs of the community. Through public consultation with the community, the RHB makes determinations of the kinds of health services needed and desired by the health region.
Providing services based on geographically drawn boundaries has had profound impact on delivery of mental health services. Different health regions have varying pre-existing infrastructures. In my experience, this has led to the restriction of movement of mental health clients and has created an environment of territoriality in the provision of service by healthcare providers. This has led to increased pressure on existing regional services, especially emergency mental health services. In my own work setting, an emergency short stay treatment facility, we have seen an increase in the acuity of clients and our client lengths of stay. The average length of stay in 1997 was six days (PCLA Admission Records, 1997). So far this year, the length of stay has increased to nine days (PCLA Admission Records, 1998). This increase in the length of stay illustrates the increased pressure on existing emergency care facilities within the community.
Another example of the effect of financial constraints placed upon the delivery of mental health services has been the policy of special authority for payment of new psychotropic agents. The newer antipsychotics and antidepressant medications are being limited in their distribution to those that have the financial resources to pay for them and those that meet stringent criteria for being declared "treatment resistive". This illustrates the interrelationship amongst the critical issues that affect the therapeutic environment.
One of the more serious financial constraints is the financial resource of mental health clients and the cost of living. Using the area of New Westminster as the example, a single person, deemed unemployable is eligible for what is called a handicapped pension provided through the Ministry of Social Services and Housing. The current rate for this pension is $771.00 monthly. This rate is inclusive of shelter, food, clothing, transportation and any other comforts required by the recipient. According to the Housing Registry in New Westminster (personal communication March 12, 1998), the cost of a bachelor apartment ranges between $450.00 - $550.00 monthly. These were average numbers for the city of New Westminster. Considering that the handicapped pension is all-inclusive, after paying for shelter, little money is left for the purchase of food, clothing, transportation and other items. This has contributed to the burden being placed on already stretched emergency services. The impact of limited financial resources of mental health clients can be best summarized by a comment attributed to a mental health client in the 1998 Mental Health Plan. He stated that "I managed to get a van (to live in). The police checked me out one day…and said, "Find a place when you can". It's been four years now" (1998, p. 12).
Deinstitutionalization from its inception decades ago has encountered obstacles every step of the way. As Barofsky and Budson note "were deinstitutionalization merely concerned with the exchange of settings for patient care, many of the problems known to exist would not have arisen" (1983, p. 16). They continue by stating "the community would simply have replaced the hospital as the locus of care, and resultant problems would have been of a logistical nature, easily negotiated and resolved" (1983, p. 16).
The process of deinstitutionalization has in many ways failed to meet the needs of the most seriously mentally ill. Barofsky and Budson ascribe this failure to "the requirements of the most seriously ill have been subordinated to those of patients who are essentially healthy but unhappy" (1983, p. 21-22). They note that this can be attributed to "those seriously impaired patients with their peculiar combination of service requirements, chronicity and impotence, have had to compete for scarce resources with others who are less seriously impaired and more socially acceptable" (1983, p. 22). Although these views are dated, they are still relevant when looking at the current state of deinstitutionalization. The 1998 Mental Health Plan notes that "patients transferring from Riverview Hospital to the community need essentially the same range of services as was available to them at the hospital" (1998, p.8). At the local level, an example of the seriously mentally ill not having ready access to necessary services was described in an interview with Dr. C. Kogan (personal communication, March 13, 1997). He reported that the day program at Royal Columbian Hospital was no longer serving its original intended purpose. He reported that the program was established as a means of providing ongoing monitoring of first break Schizophrenics. He reported that at present the day program is clogged with clients having a personality disorder.
Pharmacological Breakthroughs
From the late 1980's to present, advances have been made in pharmacotherapy resulting in the discharge of chronic patients to the community. These advances have produced new atypical antipsychotics and classes of antidepressants that have fewer side effects combined with desirable effects on such things as the negative symptoms of schizophrenia.
Littrell, Peabody and Littrell, in their study of Olanzepine as a new atypical antipsychotic (cited in The Journal of Psychosocial Nursing, 1996 pp. 41-46) attributes the improvements in pharmacotherapy as being "a major force in creating the paradigm shift in the treatment of schizophrenia in which expectations are now focused on improvement rather than stabilization". As earlier noted, these medications are not presently available to everyone due to pharmacare restrictions for payment of the medication. Therefore, while advances are being made in pharmacology, only those with sufficient financial resources or those meeting the criteria of treatment resistive as defined by the pharmacare plan are eligible to receive these medications.
Treatment failures can result for a number of reasons. Jones notes that treatment failures includes "those clients characterized by uncertain diagnosis, clients with a tendency to acting out and clients with intense separation reactions" (1998, p. 3-19). Barofsky and Budson describe these failures as "patients who appear not to fit into the system despite persistent efforts to engage in an ongoing treatment process, keep returning to the emergency ward where they constitute a familiar revolving-door population" (1983, p. 22). Although not eloquently stated, Lamb (cited in Barofsky and Budson, 1983 p.22) refers to those emergency ward regulars as "psychiatric hoboes". This revolving door is evident in my workplace. For the year ending 1997 60% of admissions to my facility had a previous admission within the prior calendar year (PCLA Admission Records, 1997). Despite these observations, the "revolving door syndrome" may in fact not truly represent a treatment failure. Kramer and Rubinson (cited in Barofsky and Budson, 1983 p. 22) write "visits by former patients frequently reflect either "meaningful relationships with staff members and other patients" or "continuing treatment needs of various kinds". Support on this point is provided by Gruber, Brown and Mazarol (cited in Barofsky and Budson, 1983 pp. 22-23) who note that "visits by these patients represent a response to real but unarticulated needs that are not being met by the mental health system and that while hospital readmission is commonly thought to indicate failure, it may be better to look on the brief hospital admission as an episode of temporarily increased dependency in the course of a long-continuing disability".
The Unit Team
With deinstitutionalization came the transfer of care from the hospital to community care teams. This transfer from hospital to the community led to the development of an array of support services. The creation of these services increased the number of unit teams that would now be providing service to the client. The proliferation of these unit teams or treatment teams brought new professional and non-professional staff with a multitude of different backgrounds, education, experience, values and attitudes together with the common goal of serving the needs of the client.
The approach of setting up these separate inpatient and outpatient treatment teams makes provision of service fragmented for the client. Barofsky and Budson believe that "chronic patients suffer most from our tendency to keep inpatient and outpatient staffs separate, and to move the patient from one clinical team to another when the locus of treatment needs to be changed" (1983, p. 40). Panzetta (cited in Barofsky and Budson) concurs with this assessment of separating the treatment teams. He notes that "outpatient staff tended to see the patient as having been rushed out of the hospital without adequate treatment or preparation. The inpatient staff tended to see the outpatient staff as disorganized and unwilling to follow up on patient needs"(1983, p. 40). This highlights the differences between inpatient and outpatient services and is consistent with what I find occurring in my own practice. Working in an emergency short stay facility puts me between the mental health centres (outpatient treatment) and the hospital (inpatient treatment). It is common to hear that the mental health centre believes the hospital has failed to keep the patient long enough and to provide adequate treatment. Conversely, I often hear the hospital complaining that if the mental health centre was more organized and coordinated in its provision of service that the client would not be in the hospital in the first place. These conflicts may in part be related to what Bell and Ryan (cited in Jones, 1998 p. 3-19) see as being staff values that may conflict with the concept of the therapeutic community. Those values identified are "treatment precepts (involving contradictory therapeutic precepts), leadership (being involved in other demanding pursuits at the same time), power relations (different ideals held by professionals and non-professionals) and attitudes towards clients (containment of and controlling client behaviours)".
Staff Morale
The demands placed on the professional psychiatric nurse are many. As members of multidisciplinary teams consisting of a mix of other professionals and non-professional staff, we function in a variety of different roles. We act as team leaders, case managers, providers of direct care, client advocates and health educators. These roles are being fulfilled in a period of uncertainty within our present healthcare system.
In examining staff morale, an understanding of the interrelationship of the other critical issues is necessary. Shrinking healthcare budgets mean we work harder with less. Changes in the delivery of healthcare require creative adaptability. Advances in pharmacotherapy necessitates creativity in delivering components of care not related to pharmacology, which has brought about briefer periods of hospitalization for the seriously ill.
Another aspect of professional relationships that could affect the therapeutic environment is the history of psychiatric nursing in context of the health care system and the ongoing division between Registered Nurses and Registered Psychiatric Nurses. As Duncan notes "Given the history of the health care system and psychiatric nursing there has been a constant struggle to be a colleague with other professionals and not just the person who carries out the doctors orders" (1997, p. 5-10). Duncan further notes "add to that reality the even more painful reality of the division within the profession of nursing itself. There exists the Registered Psychiatric Nurses Association of British Columbia and the Registered Nurses Association of British Columbia with members practicing psychiatric nursing in competition with each other for employment and status" (1997, p. 5-10). In considering how this might impact on the therapeutic community, Duncan states "individually you may work on a team with effective team relationships. The fact remains that there is not a cooperative effort being generated between the two professional associations to professionally heal the damage that continues to effect nurses and ultimately the standard of care to clients and communities" (1997, p. 5-10).
Therapeutic Community Factors
In today's delivery of mental health care, especially facility care, clients of differing pathologies and degrees of severity are cared for on the same unit. When considering therapeutic community factors, Jones notes that "the therapeutic community can fall victim to the clients' psychopathology" (1998, p.3-18). This means that under certain circumstances and conditions, the clients illness may interfere with the principles of a democratic setting. In considering examples of such situations, Jones notes "when manic and borderline personality disorder clients are in a group surrounded with a stimulating atmosphere they may become more difficult then they would normally be" (1998, p.3-18-3-19). Jones also notes that "the therapeutic community can exert a harmful and regressive effect on the client with character disorders because of their specific rehabilitation needs. That is, for example, it may allow more opportunity for manipulation of clients and staff" (1998, p. 3-19).
The examples of Jones provides for an illustration of the difficulties that can be encountered when trying to implement the general principles of a therapeutic community with such a diverse patient population in a single treatment setting.
Treatment Models
One goal of the therapeutic community is democracy. This goes to the belief that clients are active participants in their own treatment. Jones notes that "the emphasis on democratization may compromise the essential goal of individualized therapy" (1998, p. 3-18). Also noted by Jones is that "attention has therefore to be paid to the composition of groups" (1998, p. 3-18). In today's health care system, little attention is paid to the composition of groups in a care setting. With the restriction of health care monies, clients are placed in the first available bed. Ward settings and indeed community settings provide care to a diverse patient population with varying illnesses and varying degrees of severity. The acute client is mixed with the chronic client and the symptomatic client is placed with the asymptomatic client. This indeed has been my experience in my own facility. The composition of clients is dictated by the one in and one out method of service delivery.
This section explores potential solutions to threats posed to the therapeutic community. The solutions explored relate to accountability, leadership, client advocacy and acting as a change agent. Each solution is presented separately.
Leddy and Pepper indicate that to be accountable "a profession must know what it is accountable for. It does this by establishing professional standards and attempting to enforce them" (1993, p. 273). This accountability, as described by Leddy and Pepper is to "the client and public, the profession, to self and the employing agency" (1993, p. 274-279).
In looking at nursing responsibility to the client and public, Leddy and Pepper believe that "the consumer has the right to receive the best possible quality of care, care grounded in a firm knowledge base and performed by those who can make use of that knowledge base by applying sound judgement and a clear and appropriate value system" (1993, p. 274). In expanding this view beyond individual clients, Leddy and Pepper state "as a knowledgeable professional, the nurse should be ultimately accountable for health care delivery nationally. When she seeks to blame others (such as physicians, administrators or politicians) for the state of the health care delivery system, she weakens her position and her power base" (1993, p. 275). In accepting an appropriate degree of responsibility for the current situation and actively pursuing methods of improving it, Leddy and Pepper state "the nurse acts on a more professional level and stakes her claim to a piece of the health care pie" (1993, p. 275). Psychiatric nurses possess the knowledge base to provide the best quality care possible for the clients that we serve. This knowledge and expertise translates in a power base. It is the responsibility of every psychiatric nurse to use this knowledge and expertise to influence national and local health care issues related to mental health. A means of achieving a place on the national and local stage is through advanced levels of educational preparation and research. Advanced education and continuing research in psychiatric nursing would place psychiatric nurses in the forefront of decision making related to mental health policy. When policies are implemented that are contrary to the therapeutic environment, psychiatric nurses must ensure that they are part of the decision making process. Whether the issue is regionalization of health services or continued deinstitutionalization, psychiatric nurses need to accept responsibility for their practice and must ensure that the needs of the client are clearly articulated to those in decision making circles. When policies are presented that are detrimental to the well being of the client, we must use our knowledge and expertise to assist in reformulating policies so that the needs of the client are met. This means providing the best possible quality care that is currently available.
In the nurses accountability to the profession, Leddy and Pepper report that "the nursing profession in exercising its accountability toward itself in the performance of its duty to formulate its own policy and control its activities" (1993, p. 275). A nurses accountability to the profession according to Leddy and Pepper includes "the need to be aware of and accountable not only for her own actions but also for those of her colleagues" (1993, p. 276). In discussing the nurses accountability to the profession, the education of its members is also important. Leddy and Pepper note "the nurse is also accountable to the profession when she considers the issue of which educational system will prepare its members most satisfactorily for practice. It is not enough to let nursing be buffeted by external winds of change or by individuals and forces outside its perimeter" (1993, p. 276). In British Columbia, the Registered Psychiatric Nurses' Association of British Columbia (RPNABC) regulates the practice of Registered Psychiatric Nurses. The RPNABC (1995, pp. 13-35) sets competencies expected of the beginning practitioner of psychiatric nursing, outlines the minimum standards of practice required of all practicing psychiatric nurses and provides a code of ethics to ensure the moral and ethical practice standards of psychiatric nursing are maintained. Each nurse has a moral, ethical and legal obligation to ensure that the standards of practice are not only met but also constantly challenged and exceeded. The status quo is not the goal of nursing. The forward movement of health attainment and betterment for all is the goal of nursing. Standards of practice and competencies need continual review and revision to ensure they reflect current standards of care and practice.
When examining the nurses accountability to self, Leddy and pepper believe the nurse "must be the one responsible for maintaining her own mental and physical health and for keeping all aspects of her life in a balanced perspective" (1993, p. 277). Accountability to self involves the nurse being self-aware. Leddy and pepper note this includes "refusing to work in situations that she considers unsafe, either because of her own lack of knowledge or experience in an area or because of insufficient staffing or some other problem inherent in the situation itself" (1993, p. 277). Leddy and Pepper continue by noting the nurse must "acknowledge personal limitations and recognizing the need for further education to be more fully and safely perform the nursing role" (1993, p. 277). There are factors outside nursing which influence the nurses accountability to self. As Leddy and Pepper note "government can aid or hinder the nurses ability to do her best through legislation, funding of education and research and health care priorities. The nurse must consider political activism, a means to ensure accountability to self, as a method of bringing public policy and the most expert care into congruence" (1993, p. 277). Political activism includes lobbying efforts at both the individual and association level. Although the association has the protection of the public as its main mandate, it must also assume lobbying efforts on behalf of the profession to advance the expertise and knowledge of the psychiatric nurse in looking at the complex issues related to mental health care delivery. When a nurse recognizes limitations in their knowledge, skills and abilities, it is incumbent on every nurse to further increase their knowledge, be it through education, research or sharing of knowledge related to advanced practice.
In describing leadership, Bennis and Nanus (cited in Leddy and Pepper, 1993 p. 397) state "leadership is what gives nursing its vision and its abilities to transform clients' health". They further note that "this transformation occurs through the leader's translation of vision into reality with clients" (cited in Leddy and Pepper, 1993 p. 397). Within this transformational relationship, Leddy and Pepper note it is "characterized by the sharing of power rather than the wielding of power by the nurse" (1993, p. 398). This leadership based on the sharing of power can have powerful impact on health policy decisions related to the delivery of health care. In describing how nurses can best use their leadership and power base, Leddy and Pepper state "nurses potentiate their power more when they unite using the power of numbers and associative power with the consumer to generate support for desired policies" (1993, p. 406). Leddy and Pepper further note that "the collective power of nurses exercising expert power with clients and interpersonal power with unified purposes could be a major force toward reshaping the health care delivery system" (1993, p. 406). When issues of importance are identified by our clients, psychiatric nurses have an obligation to work with clients to effect necessary change. If clients of mental health and psychiatric nurses' join together on health related issues, the numbers would be overwhelming. Strength comes in numbers in that the profile of issues are elevated in the public domain and decision and policy makers are then forced to not only look at the issue but to seek input from stakeholders as to how issues can best be dealt with.
Client Advocate
The nurse as a client advocate has positive implications for the client, the delivery of health care and the image of the profession in the eyes of the public.
Newman (cited in Leddy and Pepper, 1993 p.438) indicates that when the nurse acts as an advocate for the client "the professional enters into a partnership with the client with the mutual goal of participating in an authentic relationship, trusting that the process of its evolving, both will grow and become healthier. Our goal is not to change the client; rather, it is to be with the client as he identifies his concerns and the actions he wants to pursue". In this context, Leddy and Pepper note "power is shared and neither the nurse nor the client is placed in a dependent relationship" (1993, p. 438).
For the client, Leddy and Pepper indicate that "whenever the client perceives that the nurse not only has truly acted on his behalf to ensure adequate health care but also has respected his ability to assume responsibility for his own health and make his own decision, he grows in feelings of personal worth and competence, and the nurse gains respect and appreciation for professional services" (1993, p. 449). From this respect and appreciation for professional services, the morale of the professional psychiatric nurse could certainly be enhanced through increased satisfaction in knowing that the client has been empowered to help themselves.
In increasing respectability with the public, in acting as advocates, Leddy and Pepper state "the fulfillment of the advocacy role with clients, therefore, gives nurses excellent opportunities to influence society's image of nursing. It offers the opportunity to portray an image of a professional person who brings about a good result . . . and as giving selfless attention to a client's affairs" (1993, p. 449).
In examining how the nurse as a client advocate can change the delivery of health care, the perception of the public is important. Leddy and Pepper indicate that "public support cannot be underestimated. Both a public image of the nurse as competent and an appreciation of the nurse's advocacy efforts with build public support" (1993, p. 448). The importance of this public support is noted by Leddy and Pepper as being "one of the most powerful forces for change in society" (1993, p. 448). Having this support, Leddy and Pepper note "nursing can use the public's help to restructure the health care delivery system" (1993, p. 448). This support of the public has other benefits to nursing as Leddy and Pepper indicate that "as nurses gain the respect of the public they serve, the more likely they are to gain the respect of interdisciplinary peers" (1993, p. 448).
Change Agent
The role of change agent requires accountability, leadership and client advocacy on the part of the professional nurse. To act as a change agent, according to Leddy and Pepper, the nurse must as a first step "is to identify dissatisfaction with the current state" (1993, p. 418). When individuals are satisfied with the way things are, there can be little motivation to change. This can be viewed as resistance to change. In identifying this potential resistance, Leddy and Pepper note "the agent may need to unfreeze the organization by making persons receptive to change" (1993, p. 418). Strategies for making organizations receptive to change as described by Leddy and Pepper include "creation of dissatisfaction with the status quo, building in participation in the change, giving participants the time and the opportunity to disengage from the present state, and building in rewards for the desired behavior" (1993, p. 418).
Wooten and White (cited in Leddy and Pepper, 1993 pp. 426-427) have identified five basic change agent roles. These roles are educator/trainer, model, researcher/theoretician, technical expert and resource linker. These roles are filled by psychiatric nurses at every level of practice making the psychiatric nurse the ideal change agent. As an educator/trainer, the psychiatric nurse may be engaged in the formal education of other nurses or providing health teaching and education to clients and the communities that we serve. Psychiatric nurses through their practice act as models not only for other nurses but other professional and non-professional staff that we interact with every day. Our specialized knowledge, skills, experiences and abilities makes us the "technical" experts in the field of psychiatric mental health nursing. As nurses, particularly those in community, a large portion of our work is resource linking on behalf of the client and the agency.
When psychiatric nurses identify themselves as change agents, recognize the change agent roles we assume and combine that with accountability, leadership and advocacy on behalf of our clients, the therapeutic community can be maintained while expanding the role and scope of psychiatric nursing practice.
As discussed, many factors can threaten the establishment and continuance of the therapeutic community. These factors are interdependent on one another, as no one factor is solely responsible for potential disruption to the therapeutic community.
The professional psychiatric nurse is in a unique position to ensure the development and continuance of a therapeutic community be it at the unit level or the larger health care delivery system. Through demonstration of professional behaviours which include professional accountability, leadership, client advocacy and by acting as a change agent, the professional psychiatric nurse can ensure that the therapeutic community is maintained and thrives in the face of uncertainty in the ever changing and evolving health care system.
Barofsky, I., Budson, R. (1983). The chronic psychiatric patient in the community: principles of treatment. Jamaica, New York: Spectrum
Duncan, K. (1997). Professional psychiatric nursing concepts (3rd ed.). New Westminster, British Columbia: Douglas College
Jones, D. (1998). Adjunctive therapies: issues and interventions in psychiatric nursing practice (4th ed.). New Westminster, British Columbia: Douglas College
Leddy, S., and Pepper, J.M. (1993). Conceptual bases of professional nursing (3rd ed.). Philadelphia, Pennsylvania: J. B. Lippincott
Littrell, K., Peabody, C.D. & Littrell, S.H. (1996). Olanzepine: A New Atypical Antipsychotic. Journal of Psychosocial Nursing, 34 (8), 41-46.
Ministry of Health Responsible for Seniors (1998). The 1998 mental health plan: revitalizing and rebalancing british columbia's mental health system. Victoria, British Columbia: Government of British Columbia
Pioneer Community Living Association (1997). Admission records and statistics. New Westminster, British Columbia: Pioneer Community Living Association
Pioneer Community Living Association (1998). Admission records and statistics. New Westminster, British Columbia: Pioneer Community Living Association
Registered Psychiatric Nurses Association of British Columbia (1995). Competencies expected of the beginning practitioner of psychiatric nursing standards of psychiatric nurses in british columbia code of ethics Coquitlam, British Columbia: Registered Psychiatric Nurses Association of British Columbia
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