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Автор неизвестен - Mededworld and amee 2013 conference connect - страница 33
Background: Developing an appropriate attitude and sensibility of professional values and behaviour is a consistent goal of medical education. There is comparatively little understanding of how medical students' attitudes and values of professionalism develop during the course of their medical education. Summary of work: A study was carried out to analyse the changes in Japanese medical students' perception of a good doctor as they progressed through medical school. Year 1, 4 and 5 students participated in this study. The relative importance of each of seven attributes of a good doctor: 'excellence', 'accountability', 'basic medical knowledge', 'clinical competences in therapy', those in 'diagnosis', 'morals and ethics', and 'communication skills' was estimated by a statistical method, Conjoint analysis. Summary of results: Year 1 students most emphasised 'clinical competences in therapy', followed by 'communication skills'. Unlike the results of the previous studies, 'morals and ethics' was the fifth importance of them. Gradually from Year 1 to 5, the relative importance of 'communication skills' declined, and in contrast, those of 'clinical competences in therapy' and 'diagnosis' increased. Year 5 students emphasised less on 'morals and ethics' and 'excellence' than Year 4 and 1 students did.
Conclusions: The students appeared to change their attitudes and values of professionalism as they progressed through medical school. The preferences of Year 5, who had experienced clinical clerkship, seemed to become more realistic than those of Year 1. Take-home messages: The students' development was influenced by informal and hidden curricula in clinical
settings. This seemed to reflect social demands for doctors and not necessarily be negative as generally believed.
Yellow Card - Professional Attitudes and Behaviour
P Bjelogrlic (University of St Andrews, School of Medicine, Medical and Biological Sciences Building, St Andrews KY16 9TF, United Kingdom) E Sinclair (University of St Andrews, School of Medicine, St Andrews, United Kingdom)
A Laidlaw (University of St Andrews, School of Medicine, St Andrews, United Kingdom)
Background: Forming attitudes, cultivating desired behaviour and ultimately promoting professionalism is an important aspect of medical education from day one. To encourage students to adopt the GMC's (General Medical Council) guidance "Medical Students: Professional behaviour and fitness to practise", the School of Medicine, University of St Andrews, introduced a yellow card warning system. Summary of work: For one cohort of medical students (n151), year of entry 2010, yellow card data was recorded for three years. The data was entered into an Excel spread sheet and included date of card issue and the reason for issue. We have reviewed and identified trends in delivery of yellow card warnings. The results will be presented.
Summary of results: The number of warnings issued varied for each semester. Distribution was not uniform throughout the semesters. We have reviewed and identified trends in delivery of yellow card warnings. We reflected on these trends and propose how the yellow card system influenced and improved students' understanding of professional behaviour. Conclusions: The yellow card scheme is an effective tool to influence attitudes and behaviour and make students more aware of the GMC's guidance: "Medical Students: Professional behaviour and fitness to practise" Take-home messages: Raising awareness of professionalism using a yellow card system from day one at medical school influences students' attitudes and behaviour.
3DD Posters: Problem Based Learning Location: South Hall, PCC
PBL - What next?
Nicholas Latcham (Hull York Medical School, Medical Education, 47 Main Avenue, York YO31 0RR, United Kingdom)
Elizabeth Hughes (Hull York Medical School, Medical Education, Hull, United Kingdom)
John Lewis (Hull York Medical School, Medical Education, York, United Kingdom)
Background: Problem Based Learning (PBL) was introduced into medical education in 1969 and has become an internationally accepted educational tool. It has, however, shown little evolution in over 40 years. Summary of work: Junior doctors in academic posts in medical education at Hull York Medical School (HYMS) are investigating the potential development of PBL within HYMS. A preliminary review of published literature suggested there was no universally accepted definition of PBL. To explore its development, it is important to clarify what PBL is perceived to be. Summary of results: A literature review confirmed that there was no universal definition of PBL, although recurrent themes were highlighted. There is little published literature on how PBL should be developed. In comparison to traditional courses, PBL seems to be effective in social and cognitive domains. Its relative effectiveness in the acquisition of knowledge remains contentious. This may in part be due to the complexity of variable implementations of PBL. Conclusions: Research should be conducted into defining what PBL is and how it should be developed. Qualitative research methods are being used to answer these questions.
Take-home messages: We should avoid complacency in our use of PBL. Educational research can be used to develop junior academics and to inform educational development and policy.
10 years' experience of PBL in Kyungpook National University School of Medicine
Sang Hee Yeo (Kyungpook National University School of Medicine, Department of Medical Education, 101 Dongin-dong, Jung-gu, Daegu 700422, Korea, Republic of (South Korea))
Bong Hyung Chang (Kyungpook National University School of Medicine, Department of Medical Education, Daegu, Korea, Republic of (South Korea)) Jong Myung Lee (Kyungpook National University School of Medicine, Office of Medical Education, Daegu, Korea, Republic of (South Korea))
Jang Soo Suh (Kyungpook National University School of Medicine, Department of Laboratory, Daegu, Korea, Republic of (South Korea))
Chang Ho Youn (Kyungpook National University School of Medicine, Department of Medical Education, Daegu, Korea, Republic of (South Korea))
Background: The purpose of this study is to investigate the students' satisfaction in PBL, the students' preference for the number of PBL sessions per week and per case, the sequence of PBL and related lecture, and the preference for the presence of a tutor in the group. Summary of work: The target period in our study is from 1999 to 2009, and target students are from second year. Satisfaction with PBL was investigated in 2002, 2005, and 2009. The rest of the study topics as mentioned above were investigated in 2009. Surveys were conducted during PBL class. We had a focused interview with group leaders and some students after class. Summary of results: The scores of PBL satisfaction based on a 7-point scale were 4.95 points in 2002, 5.62 points in 2005, and 5.00 points in 2009. 69 respondents (70.5%) among 97 students preferred to study throughout the semester to the short term. Among 109 students, 92 respondents (84.4%) preferred to meet once a week and to study a case every two weeks. 59 respondents (54.1%) preferred attendances of tutor to absences in the group. It was investigated that 94 respondents (95.9%) in 2004 and 57 respondents (52.3%) in 2009 preferred to learn PBL case related to lecture contents. 85 respondents (78%) in 2009 preferred to take a PBL session after lecture. Conclusions: As a result, in order to increase students' satisfaction with PBL, it is necessary to arrange the date and the time of PBL session so that students can concentrate on PBL. Secondly, we should select PBL case to develop the ability of students' problem solving by arranging PBL case not to be synchronized with ongoing lecture contents.
Take-home messages: Finally, we should help make an atmosphere where students feel free to talk during PBL session.
Teaching Neurosciences in an Integrated Problem-Based Learning Program in an Undergraduate Medical Curriculum: Students' and Tutors' Perceptions
Ahmed Al Rumayyan (King Saud bin Abdulaziz University for Health Science, College of Medicine, P.O. Box 3660, MC3130, Riyadh 11481, Saudi Arabia)
Background: This paper aimed to briefly explore students' and tutors' perspectives regarding relevance, stimulation and amount learned from ten problems presented as triggers of learning in the Neurosciences, Vision and Behaviour Block in a problem-based curriculum at the College of Medicine, King Saud bin Abdulaziz University for Health Sciences. It is well known that the nature of student learning in PBL is largely dependent on the quality of the cases presented to them.
Summary of work: To describe teaching of the Neuroscience, Vision and Behaviour block in an
integrated PBL undergraduate medical curriculum and to discuss students' and tutors' perceptions of relevance, stimulation and amount learned from the problems used as triggers for learning. Summary of results: Students and tutors had favorable, congruent perceptions of amount learned, stimulation and relevance of neuroscience problems in a Saudi Arabian healthcare context. Open-ended comments from both groups were highly supportive of the block objectives, content and integrated teaching. Conclusions: It is important to evaluate amount learned, relevance and stimulation of problems as triggers of learning in a problem-based curriculum. This is particularly important where problems have been developed in a socio-cultural context that is different to that in which they are being implemented. Often students' perspectives are the only evaluation feedback elicited but tutors are also well placed to provide insights into functioning of PBL problems. Take-home messages: Exploring the congruence of students' and tutors' perspectives has been helpful when determining necessity for neurosciences block modifications, emulating a PBL collaborative knowledge-building approach in curriculum development.
PBL in Parasitology: A pilot project in a transforming medical school
Tatiana Giusti-Ehlert (Universidad Central de Venezuela, Centro de Investigacion y Desarrollo de la Educacion Medica, Escuela de Medicina "Luis Razetti", Ciudad Universitaria, Caracas 1053, Venezuela) Juan Perez-Gonzalez (Universidad Central de Venezuela, Centro de Investigacion y Desarrollo de la Educacion Medica, Caracas, Venezuela)
Background: In a transforming medical school, where a competency-based curriculum is due to replace a traditional one, there is a need for gradual implementation of student-centered, competency-developing learning strategies. This is a particular challenge in basic disciplines such as Parasitology. We describe an attempt to develop a PBL course to complement traditional teaching methods for third-year medical students.
Summary of work: The traditional Parasitology course requires students to complete 3 activities for each program topic: lectures, practical sessions and tutorials. We substituted the latter for PBL-type sessions based on cases depicting the clinical presentation of various parasite groups to promote in-context learning within traditional learning objectives. Cases were delivered to students, via the Edmodo platform, one week prior to each session in which four randomly-selected students make a 15-minute presentation of their reasoning and conclusions. A further 45-minute general discussion follows, to construct group-learning. Students are encouraged to use a structured clinical reasoning approach to problem-solving. Students' performance is assessed after each session by the tutor, with summative purposes, using Elizondo-Montemayor's
criterion-referenced system. Formative self-assessment and peer-assessment is carried out periodically. Summary of results: Students are followed up and their performance in the traditional course is compared to a control group. Self-directed learning skills are assessed before and after the course in both groups, as is student satisfaction with the learning process. Take-home messages: PBL, adapted to a traditional curriculum is a suitable method to enhance knowledge application and self-directed study in Parasitology. Furthermore, it helps to familiarize students and faculty with strategies aimed to develop significant learning.
Satisfaction of medical students towards a change from problem-solving approach to problem-based learning in a 3-week renal system block
Promjit Sriyabhaya (Srin akharin wirot University, Pathology, 114 Soi 23 Sukhumvit Rd., Wattana, Bangkok 10110, Thailand)
Nantana Choomchuay (Srinakharinwirot University, Pathology, Bangkok, Thailand)
Background: In 2012, problem-based learning (PBL) activity was initially implemented as the first session of the renal system block at Srinakharinwirot University. Some faculty members, however, disagreed to this change as they believe that undergraduate students would be more satisfied and perform better if lectures in anatomy and physiology of the renal system are provided prior to problem-solving sessions. Summary of work: The authors investigated whether a change from problem-solving to PBL affected exam performance and satisfaction of students on teaching and learning activities by comparing the data obtained from students completing the course in 2012 and the previous year.
Summary of results: A change from problem-solving to PBL did not significantly affect the performance of students on the in-house examination, with an average score of 71% in 2012 versus 73% in 2011. In addition, there was no significant difference of the satisfactory scores on an evaluation of teaching and learning activities between the year 2011 and 2012, with the average scores of 4.47/5 and 4.48/5, respectively. Importantly, most students (95%) highlighted the challenge of PBL scenario and the fulfillment of supplementary lectures as they came to the class with meaning instead of just for simply listening. Conclusions: Hence, students were satisfied with structuring PBL at the beginning of the course although it is challenging.
Take-home messages: To improve performance of students, the faculty should familiarize students with PBL rather than holding a lecture.
Problem based learning: a more rewarding learning experience?
F Mughal (University of Birmingham, School of Population and Health Sciences, Birmingham, United Kingdom)
A Ryan (University of Birmingham, School of Population and Health Sciences, Birmingham, United Kingdom) C Barton (University of Birmingham, School of Population and Health Sciences, Edgbaston, West Midlands, Birmingham B15 2TT, United Kingdom) R Stores (University of Birmingham, School of Population and Health Sciences, Birmingham, United Kingdom) H Lee (University of Birmingham, School of Population and Health Sciences, Birmingham, United Kingdom) J Clark (University of Birmingham, School of Population and Health Sciences, Birmingham, United Kingdom)
Background: There is evidence demonstrating that problem-based learning (PBL) is a more rewarding learning experience for students, and that students generally favour PBL against 'lecture-based' traditional pedagogy. There is, however, limited research that compares student satisfaction and their learning behaviours when both teaching methodologies are applied to a single cohort. This study aims to reflect on the effectiveness of current teaching techniques, endeavouring to increase student enjoyment in learning. Summary of work: A cross-sectional study of 260 undergraduate medical students at the University of Birmingham was undertaken, with questionnaires exploring students' preferred teaching methodology, learning resources and their learning behaviours. Summary of results: An overwhelming majority of students preferred traditional teaching over PBL, with a more accessible structure and greater clarity being fundamental reasons. The internet was the commonest resource used in PBL study, whereas textbooks were the most used resource in traditional learning. There is no significant difference between both teaching methodologies in the average time students engaged in library study.
Conclusions: Despite the growing integration of PBL into medical school curricula, this study demonstrates a population where the majority of students prefer traditional pedagogy. To achieve a more rewarding learning experience from PBL whilst enabling students to develop responsibility for managing their own learning needs, we recommend a phased integration of PBL into medical education with a concerted effort to establish a positive PBL ethos with clearer objectives which students can use as a foundation for lifelong learning.
Take-home messages: It is necessary to identify the positive aspects of traditional teaching and appropriately implement this into PBL methodology.
Problem-based learning assessment in school might predict the medical students' performances in pediatric clerkship training
LS Ou (Chang Gung Memorial Hospital, Department of Pediatrics, 5, Fu-Hsing St., Kwei-Shan, Taoyuan, Kwei-Shan 33305, Taiwan)
RH Fu (Chang Gung Memorial Hospital, Department of Pediatrics, Taoyuan, Taiwan)
CC Jenq (Chang Gung Memorial Hospital, Department of Nephrogy, Taoyuan, Taiwan)
JL Huang (Chang Gung Memorial Hospital, Department of Pediatrics, Taoyuan, Taiwan)
HJ Tseng (Chang Gung Memorial Hospital, Biostatistical Center for Clinical Research, Taoyuan, Taiwan) SJ Yeh (Chang Gung Memorial Hospital, Department of Cardiology, Taoyuan, Taiwan)
Background: The problem-based learning (PBL) is a strategy for medical learning between school to clinical workplace learning. We want to explore whether the assessments in PBL might predict the clinical workplace performance later.
Summary of work: Ninety-five medical students from Chang Gung University received PBL training in the fourth year at school and clerkship pediatric training in the fifth year at Chang Gung memorial hospital. Six different PBL training scores in school were compared with the five different scores in pediatric clerkship training.
Summary of results: The relationship between different PBL scores and clinical pediatric assessment scores showed moderate, low, or poor correlation. We found that PBL scores of behavior assessment from tutors is a better prediction factor than PBL written test. The students in upper 25% ranking of PBL assessment from tutors had better performances in three kinds of pediatric clerkship assessments (case-based discussion score, assessment score by resident supervisors, and on duty performance score, all p<0.05) than students in lower 25% ranking of PBL assessment from tutors. Conclusions: PBL assessment scores by tutors in school might reflect the medical students' learning and working ability in the future and might help us to predict or find students to improve their clinical learning strength. Take-home messages: PBL assessment scores by tutors might predict the medical students' learning and working ability in the future.
Students', Tutors' and Experts' perspective of the Effective PBL Problems
Savitri Shitarukmi (Faculty of Medicine Universitas Gadjah Mada, Medical Education, Jalan Farmako, Sekip Utara, Perumahan Jombor Baru Blok 2 No 12 Sleman, Yogyakarta 55285, Indonesia) Siti Rokhmah Projosasmito (Faculty of Medicine Universitas Gadjah Mada, Medical Education, Yogyakarta, Indonesia)
Herma Roebertsen (Faculty of Health, Medicine and Life Science, Maastricht University, Educational Development and Research, Maastricht, Netherlands)
Background: A PBL problem should be designed as an effective starting point for students to attain learning objectives. Thus, a continuous monitoring, evaluating, and improving the PBL problems should be done systematically. The aim of this study is to evaluate the effectiveness of PBL problem by involving students, tutors and experts of PBL principles. We do hope that the results of this evaluation could give us about the importance of maintaining the quality of PBL problems. Summary of work: A survey by using questionnaire based on six factors of an effective PBL problem was conducted to obtain students, tutors and experts perception towards the effectiveness PBL problems used in tutorial session. The perceptions were then analysed by using descriptive statistic. Four open ended questions included in the questionnaire were used to get better understanding and explanation of quantitative result. Summary of results: Some differences among students, tutors and experts in rating the overall quality on each problem were found. The strength and the weakness of each problem were also obtained. Each group of participants had their own concern regarding the most important factor for an effective PBL problem. Conclusions: The result of this evaluation could reflect the effectiveness of PBL problems in achieving students' learning objectives from different viewpoints: students, tutors and experts. This valuable information can be used by problem designers and their institutions to monitor and improve the quality of PBL problems continuously.
Take-home messages: Whenever you have a problem, always see it from different viewpoints.
Learners' success vs. learners' satisfaction: different sides of the same coin? Hints from evaluation data of a PBL-seminar on basic scientific competencies in medicine
Gotz Fabry (Albert-Ludwigs-University, Department of Medical Psychology and Sociology, Rheinstrasse 12, Freiburg 79104, Germany) Silke Biller (Albert-Ludwigs-University, Centre for Evaluation of Teaching in Medicine Baden-Wurttemberg, Freiburg, Germany)
Boeker Martin (Albert-Ludwigs-University, Institute of Medical Biometry and Medical Informatics, Freiburg, Germany)
Marianne Giesler (Albert-Ludwigs-University, Centre for Evaluation of Teaching in Medicine Baden-Wurttemberg, Freiburg, Germany)
Ariane Zeuner (Albert-Ludwigs-University, Department of Medical Psychology and Sociology, Freiburg, Germany)
Background: As the first step in a longitudinal thread on scientific competencies we developed a PBL-seminar for first year medical students. PBL-cases focused on basic issues of scientific methods and approaches. To evaluate
the seminar we used different self-assessed variables related to students' learning success as well as to their satisfaction with the seminar.
Summary of work: 340 students evaluated the seminar at the end of their first year by means of questionnaires. Summary of results: In their self-assessment students stated that their competencies had increased with regard to the learning objectives (M=1.94 vs. M=3.38, p <.001, Cohens d = 1.98). A pre-post-assessment of their scientific competencies by means of the respective scale of the Freiburg Questionnaire to Assess Competencies in Medicine (FKM, Giesler et al. 2011) also indicated an increase in competency (M=2.82 vs. M=3.11, p<.0001, Cohen's d=0.47). Students were also positive with regard to the quality of the discussion process (Group Interaction Questionnaire, GIQ, Visschers-Pleijers et al. 2005) and the guidance of their tutors. However, when students were asked in the end-of-year evaluation to rate their learning success in the seminar and their satisfaction with the seminar overall, results were rather poor (M=3.64 and M=3.54, 6-point scale, 1=very good, 6=very poor). In addition, qualitative data also indicated that many students were rather discontent with the seminar.
Conclusions: The inconsistency of these results highlights the importance of understanding possible influences on the evaluation process (e.g. point in time, reliability and validity of items).
Using Learning Analytics to Evaluate the Efficacy of Blended Learning in PBL Based Medical Course
Abdullah Alghasham (Qassim University - College of Medicine, Pharmacology, PO Box 6655, Meldia 51452, Saudi Arabia)
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It's a New Day in Public Health.
The Florida Department of Health works to protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.
FDOH in St. Lucie County Addresses County Health Rankings
March 20, 2019
The Florida Department of Health in St. Lucie County recognizes the value in measuring health outcomes and today acknowledged the 2019 County Health Rankings & Roadmaps tool released by the University of Wisconsin and the Robert Wood Johnson Foundation. This study highlights the many community factors that influence health and uses established data, much of which is available from the department at www.FLHealthCHARTS.com.
"Through the years, the county health rankings have provided us with a tool, making certain we are on track to building a strong public health system. We work every day to bring together community partners around shared goals to collectively improve the health of our residents. As we look at successes in this year's rankings, children in poverty is 19%, a significant improvement from last year's 26%. High school graduation rate in 2016-17 is 91%, a significant improvement from last year's report of 75%. Research validates that the health, safety and wellness of children impacts their ability to learn, this is a very important high point in moving the marker forward, our children, our future" said Clint Sperber, County Health Officer for the Florida Department of Health in St. Lucie.
"The data in this report provides important insight into the needs of our students as there is a link between positive academic performance and their overall health and well-being. We know that well-nourished and healthy students are more alert and engaged in their learning" said Superintendent E. Wayne Gent – St. Lucie Public Schools.
These rankings are a snapshot of the health of counties across the country, and they emphasize that health is not a singular effort but a combined work in progress across all community partners. The department works in collaboration with local governments, non-profit organizations, health care facilities, business groups, schools, faith-based organizations and many other stakeholders to improve the health of all people in St. Lucie County. These rankings use data related to physical environments, social and economic factors, health behaviors and clinical care.
In St. Lucie County, our Community Health Improvement Plan (CHIP) is designed to address specific opportunities for improved health identified by the community. The department has partnered with many stakeholders to implement the CHIP and work in partnership regularly to track progress. Under the direction of Healthy St. Lucie, Inc., we have developed plans and activities that are improving the health of the county. The Billion Step Challenge is moving into the second year, to increase physical activity and reduce obesity, we continue to provide dental sealants in public schools, starting an age-friendly community work group to improve the health and well-being of the older adults in St. Lucie, the Baby Steps Baby Friendly initiative to increase breastfeeding among new mothers giving births in our hospitals, developing next steps following the Fetal Infant Mortality Review initiative to continue to decrease infant mortality, the Safety Village is on the charts - covering Fire Safety, Cyber Safety, Water Safety, Bike Safety, Gun Safety, Pedestrian Safety, Car Seat Safety, Electricity Safety, Traffic Safety, Health and Wellness program to improve injury prevention efforts, there is also the Tobacco Cessation Action Plan and Students Working Against Tobacco to continue to decrease smoking rates in St. Lucie County.
"The Board of County Commissioners continues to emphasize the importance of being healthy from our employee wellness programs to collaborating with the health department on projects for our residents like the Billion Step Challenge and our weekly guided nature hikes," said St. Lucie County Commission Chair Linda Bartz. "Last year, the county launched a new bike share program that ties into our fixed route bus system, giving people a chance to exercise on their daily commute, while reducing their carbon footprint."
To explore more health indicators in our county, visit www.FLHealthCHARTS.com.

subset: commoncrawl


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So, the weekend before last I posted on social media that I didn't want to be sober forever. That is … More
Tag: one year sober
What next?
It's 0130 and I can't sleep. I've got that many thoughts and ideas running around in my head and I'm … More
1 year sober
Well, where do I start? I have to pinch myself sometimes. Never in a million years did I ever think … More


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An Army officer severely wounded fighting in Iraq says the Department of Veterans Affairs won't pay for the feeding tube liquid he needs — leaving him with a hole in his stomach.
Army Maj. Dennis (DJ) Skelton penned an open letter to the VA, published Monday on Foreign Policy's website, in which he details the ordeal that left him without nourishment.
"On Saturday you had me go to the emergency room at my local hospital to place a feeding tube in my stomach because, with my shot-up palate deteriorating, it is getting dangerous again for me to eat or drink through the mouth," he wrote.
Only he didn't hear when the department would send some sort of substance.
VA officials persuaded Skelton to switch to Diabetisource after a recent surgery, he wrote. A case of 24 Diabetisources is listed on Nestle Health Source's website for $95.99.
"So today, six days post-surgery, I received a letter from you informing me that the brand you recommended to me, Diabetisource, is actually not covered by the VA and I need to go find and pay for my own feeding tube liquid on my own," he continued.
Skelton was a lieutenant in November 2004, when he was wounded fighting in Fallujah — one of the bloodiest sieges during the war in Iraq.
His recovery has gotten national attention, and was even highlighted by the Army in December 2015.
The West Point graduate was leading a platoon that got bogged down in a firefight in November 2004.
A bullet went through his left cheek, ripped apart his mouth and came out his right eye socket, according to the Army.
A rocket propelled grenade blast also tore apart parts of his left arm, while fragments dug into his right leg.
His troops used a used .50-caliber shell as an airway for their lieutenant to breathe.
Skelton persisted, recovered and returned to combat. He later set up a Boulder, Colo.-based nonprofit, Paradox Sports, for disabled people to engage in sports activities.
Even though he physically recovered, Skelton seems to still be struggling with the VA.
"So when the Secretary of the VA's front office called me last week to inquire if any of my current problems were in any way the fault of the VA — the answer is YES!" the major wrote to department.
Someone had to loan him a turkey baster so he could eat, the soldier wrote.
And while he said everyone can learn from the incident, "we don't need to use my case to shed light on everything that is wrong with the system. Just throw one or two problems at me at a time, OK? Thank you."
Skelton told the VA he was writing the letter aboard a West Point-bound train, where he was going to work on a psychology textbook chapter on "resilience."
"And now I'm giggling, which is extremely painful since I have a fresh hole in my stomach," he wrote.
The VA came under fire three years ago after reports of vets toiling ill while waiting for a doctor the department's hospitals. The scandal forced then-VA Secretary Eric Shinseki to resign and Congress to pass a reform package.
President Trump used the issues at the VA in his campaign platform, and signed an order in June that empowers the department to more easily fire negligent employees.
The department didn't immediately return a request for comment.


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Desert Update from the California Wilderness Coalition for September 2008
Desert Update from the California Wilderness Coalition for September 2008
Senate Advances CA Desert & Mountain Heritage Act
On September 11, 2008, with nearly 100 wilderness activists and volunteers present, the Senate Energy and Natural Resources Committee reported out 53 public lands bills, including the CA Desert and Mountain Heritage Act. The bill is now ready to be considered by the full Senate. If passed, the bill would protect 191,000 acres of wilderness including areas in Joshua Tree National Park and Beauty Mountain. It would also protect four rivers as "wild and scenic" including Fuller Mill Creek.
With a dwindling legislative calendar, our folks in DC and in the field are working hard to make this bill a priority for our legislators. CWC applauds the hard working volunteers as well as the bill's champions—Representative Bono Mack and Senators Boxer and Feinstein. For more information please visit: http://desertmountainwild.org.
There's more wilderness out there…
Over the years CWC has continually helped monitor existing wilderness areas and inventoried potential new wilderness areas. Here in the desert, we are at a critical and exciting juncture. With the help of dedicated volunteers, local community leaders and our coalition partners, we have readied a proposal for several new wilderness areas in the desert and we'd like YOUR help! Join us on an outing to one of these spectacular and often little known wild places. Then add your voice to the growing movement to designate these places as wilderness. Together we can ensure that wild California is protected for generations to come.
Upcoming Hikes & Camping Trips
Saturday October 4th Cady Mountains Wilderness Day Hike Meet in Barstow 8:30 AM Contact: Laurel Williams firstname.lastname@example.com 909-260-8833 for details
Enjoy a day of exploration in a landscape of rugged yellow and dark brown, horizontally striped canyons in one of the few areas where the Mojave River flows above ground. We will hike through lands that were utilized by Native Americans as a water source and Jedidiah Smith and Kit Carson traveled through in the early 1800's. Keep your eye out for the elusive desert bighorn sheep as well as other wildlife like prairie falcons, golden eagles, coyotes, bobcats, jackrabbits, antelope ground squirrels, Mojave fringe-toed lizard and the desert tortoise. Bring 2 liters of water per person, sturdy walking shoes or boots, hat, sunscreen, snacks and a picnic lunch. If you are planning on joining us, please leave a message in advance at firstname.lastname@example.com or 909-260-8833.
Sunday October 5th Big Morongo Preserve Photography Hike Meet at 7:00AM in the parking lot of the Preserve. From LA, take the I-10 East to State Highway 62 North. In Morongo Valley, turn right onto East Drive. After 1 block, turn left at Preserve sign. There is a parking lot at the end of the lane. Contact: Laurel Williams email@example.com 909-260-8833 Join CWC and naturalist and wildlife photographer David Lamfrom from the National Parks Conservation Association for a leisurely hike through biologically rich riparian forest and mesquite forest, and a foray into desert hills for a potential opportunity to view desert bighorn. Bring you camera! Our early morning start will give us ample opportunity to snap photos of the over 240 species of birds that utilize Big Morongo as a refuge. Bring 2 liters of water per person, sturdy walking shoes or boots, hat, sunscreen, snacks and a picnic lunch. If you are planning on joining us, please leave a message in advance at firstname.lastname@example.com or 909-260-8833.
Saturday & Sunday October 11-12th Surprise Canyon car camp and hike Meet in Victorville 8:00 AM Contact: Laurel Williams firstname.lastname@example.com 909-260-8833 for details Surprise Canyon is a true rarity in the California desert with its abundant year round flow of water and lush riparian habitat. We will car camp below the canyon and hike up through the thick vegetation, looking for signs of the bighorn herd that uses the canyon. Some rock scrambling and stream splashing involved. Camp potluck dinner on Saturday night. Must bring willingness to get your feet wet and an extra pair of shoes and socks. If you are planning on joining us, please leave a message in advance at email@example.com or 909-260-8833.
October 31 (eve) – November 2, Friday (eve) – Sunday
CONGLOMERATE MESA EXPLORATION/CARCAMP Contact: Laurel Williams email@example.com 909-260-8833 Come with us and explore this pristine area overlooking Owens Valley and ranges to the east. Meet Friday evening near Darwin and car-caravan to our camping location at 6500'. Moderately strenuous hike on Saturday to little-known unroaded, unmined, ungrazed area south of Cerro Gordo, threatened by the potential of an open pit cyanide heap leach gold mine. Mostly trail-less cross-country, except for part of an 1870's freighting trail between Keeler and Death Valley. Some rock scrambling. Saturday evening social and pot luck. Sunday explore the Malpais Mesa Wilderness from the 1950s Santa Rosa mine. Drive to campsite requires high clearance vehicle, carpooling at meeting point may be possible. Resource guide: Tom Budlong. Contact Laurel Williams firstname.lastname@example.com 909-260-8833 for more information.
Ways to Get Involved
Volunteer to lead a hike, host a wilderness party, or write a letter to your elected officials! There are many ways to make a difference in this exciting new campaign. To find out more and to get involved in protecting desert wilderness, please contact Laurel Williams at firstname.lastname@example.com or 909-260-8833.
Spotlight on Malpais Mesa Proposed Wilderness Additions
Conglomerate Mesa is the area's central feature. At 7,700 feet, this mesa is an astonishing plateau amidst a rugged landscape that accentuates the 3,800 foot drop from the mesa to the valley floor. The mesa's western slope features rolling badlands and from the top the view is simply breathtaking. Absolutely pristine, it is roadless and has never been settled, mined, grazed, or used by ORVs. The area contains the remains of primitive shelters and old foot and mule trails from California's mining past. A hike to the top of the mesa is rugged and the landscape dry. There is a delightful surprise for the hiker who finds the hidden summit registry at the top. as well as dramatic 360 degree views of the Owens Valley and Sierra Nevada to the west and Death Valley and Telescope Peak to the east. Mule Deer, Boghorn Sheep, Golden Eagles, and threatened Mojave Ground Squirrel are some of the areas inhabitants. A rich Joshua Trees forest dominates the midlevel elevations while creosote, low desert shrubs, and grasses are found in lower elevations. Piñon pines and Juniper trees are found toward the top. This beautiful place is at threat from the Idaho-based Timberline Resources Corporation. The company has applied to bulldoze roads and conduct exploratory drilling on this stunning and picturesque landscape.
Their exploration could lead to open-pit cyanide heap-leach gold mining.
CWC is working to protect this incredible place as wilderness.
EMAIL US AT: email@example.com | TEL: (510) 451-1450 (c)2001-2008 CALIFORNIA WILDERNESS COALITION


text:
Sadyomaraneeyam Indriyam Adhyaya
Indriya Sthana Chapter 10. Signs of instant death and incurable complications of several diseases
|Indriya Sthana Chapter 10
|Preceding Chapter
|Yasyashyavanimittiyam Indriyam Adhyaya
|Succeeding Chapter
|Anujyotiyam Indriyam Adhyaya
|Other Sections
|Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana
|Translator and commentator
|Byadgi P.S.,Jitendra Kumar
|Babu S.P.
|Khandel S.K., Babu S.P.
|Date of publication
|December 17, 2018
This chapter deals with incurable complications of several diseases which can lead to a patient to an instantaneous death. It enlists some emergency conditions for intensive care. However the many signs and symptoms listed in this chapter are manageable now by advanced medical and surgical techniques. In ancient period of Charaka Samhita, the conditions were not treatable and fatal.
Keywords: Instantaneous death, fatal signs.
Symptoms and signs which indicate the definite death of the patient is called arishta. By seeing flower, smoke and cloudy weather one can expect fruit, fire and rain respectively. In the same way certain symptoms which appear before the death of the person are called arishta.(Sushruta, Sutra Sthana.28/3) Sometimes arishtas are not recognized by ignorant vaidya due to their minuscule nature or misunderstanding or by carelessness because arishta develops instantaneously before the death of an individual. Once the symptoms developed death is certain.
The dying process usually begins well before death. As that process begins, person starts on a mental path of discovery, comprehending that death will indeed occur and believing in their own mortality. Death is a personal journey that each individual approaches in their own unique way. Nothing is concrete, nothing is set in stone. There are many paths one can take on this journey but all lead to the same destination. The journey ultimately leads to the physical departure from the body. There are milestones along this journey. Some may hit only a few while another may stop at each one, taking their time along the way. Some may take months to reach their destination, others will take only days. This chapter discusses what has been observed in research by ancient scientists which predicts the impending death. The patient afflicted with these signs and symptoms does not survive more than 3 days or 7 days. A variety of physiological changes occur in the last day and hours of life.
Sanskrit text, Transliteration and English Translation
अथातः सद्योमरणीयमिन्द्रियं व्याख्यास्यामः||१||
इति ह स्माह भगवानात्रेयः||२||
athātaḥ sadyōmaraṇīyamindriyaṁ vyākhyāsyāmaḥ||1||
iti ha smāha bhagavānātrēyaḥ||2||
athAtaH sadyomaraNIyamindriyaM vyAkhyAsyAmaH||1||
iti ha smAha bhagavAnAtreyaH||2||
We shall now expound the chapter "Sadyomaraneeyam Indriyam Adhyaya" (Signs of instant death and incurable complications of several diseases). Thus said Lord Atreya. [1-2]
सद्यस्तितिक्षतः प्राणाँल्लक्षणानि पृथक् पृथक्|
अग्निवेश! प्रवक्ष्यामि संस्पृष्टो यैर्न जीवति||३||
sadyastitikṣataḥ prāṇāmँllakṣaṇāni pr̥thak pr̥thak|
agnivēśa! pravakṣyāmi saṁspr̥ṣṭō yairna jīvati||3||
sadyastitikShataH prANA@mllakShaNAni pRuthak pRuthak|
agnivesha! pravakShyAmi saMspRuShTo yairna jIvati||3||
Oh Agnivesha! I shall describe separately the ''signs and symptoms indicative of impending instantaneous death''. The patient afflicted with these signs and symptoms does not survive. [3]
List of signs of instantaneous death
वाताष्ठीला सुसंवृद्धा तिष्ठन्ती दारुणा हृदि|
तृष्णयाऽभिपरीतस्य सद्यो मुष्णाति जीवितम्||४||
पिण्डिके शिथिलीकृत्य जिह्मीकृत्य च नासिकाम्|
वायुः शरीरे विचरन् सद्यो मुष्णाति जीवितम्||५||
भ्रुवौ यस्य च्युते स्थानादन्तर्दाहश्च दारुणः|
तस्य हिक्काकरो रोगः सद्यो मुष्णाति जीवितम्||६||
क्षीणशोणितमांसस्य वायुरूर्ध्वगतिश्चरन्|
उभे मन्ये समे यस्य सद्यो मुष्णाति जीवितम्||७||
अन्तरेण गुदं गच्छन् नाभिं च सहसाऽनिलः|
कृशस्य वङ्क्षणौ गृह्णन् सद्यो मुष्णाति जीवितम्||८||
वितत्य पर्शुकाग्राणि गृहीत्वोरश्च मारुतः|
स्तिमितस्यायताक्षस्य सद्यो मुष्णाति जीवितम्||९||
हृदयं च गुदं चोभे गृहीत्वा मारुतो बली|
दुर्बलस्य विशेषेण सद्यो मुष्णाति जीवितम्||१०||
वङ्क्षणं च गुदं चोभे गृहीत्वा मारुतो बली|
श्वासं सञ्जनयञ्जन्तोः सद्यो मुष्णाति जीवितम्||११||
नाभिं मूत्रं बस्तिशीर्षं पुरीषं चापि मारुतः|
प्रच्छिन्नं जनयञ्छूलं सद्यो मुष्णाति जीवितम्||१२||
भिद्येते वङ्क्षणौ यस्य वातशूलैः समन्ततः|
भिन्नं पुरीषं तृष्णा च सद्यः प्राणाञ्जहाति सः||१३||
आप्लुतं मारुतेनेह शरीरं यस्य केवलम्|
भिन्नं पुरीषं तृष्णा च सद्यो जह्यात् स जीवितम्||१४||
शरीरं शोफितं यस्य वाताशोफेन देहिनः|
भिन्नं पुरीषं तृष्णा च सद्यो जह्यात् स जीवितम्||१५||
आमाशयसमुत्थाना यस्य स्यात् परिकर्तिका|
भिन्नं पुरीषं तृष्णा च सद्यः प्राणाञ्जहाति सः||१६||
पक्वाशयसमुत्थाना यस्य स्यात् परिकर्तिका|
तृष्णा गुदग्रहश्चोग्रः सद्यो जह्यात् स जीवितम्||१७||
पक्वाशयमधिष्ठाय हत्वा सञ्ज्ञां च मारुतः|
कण्ठे घुर्घुरकं कृत्वा सद्यो हरति जीवितम्||१८||
दन्ताः कर्दमदिग्धाभा मुखं चूर्णकसन्निभम्|
सिप्रायन्ते च गात्राणि लिङ्गं सद्यो मरिष्यतः||१९||
स्पृष्टः प्राणाञ्जहात्याशु शकृद्भेदेन चातुरः||२०||
vātāṣṭhīlā susaṁvr̥ddhā tiṣṭhantī dāruṇā hr̥di|
tr̥ṣṇayā'bhiparītasya sadyō muṣṇāti jīvitam||4||
piṇḍikē śithilīkr̥tya jihmīkr̥tya ca nāsikām|
vāyuḥ śarīrē vicaran sadyō muṣṇāti jīvitam||5||
bhruvau yasya cyutē sthānādantardāhaśca dāruṇaḥ|
tasya hikkākarō rōgaḥ sadyō muṣṇāti jīvitam||6||
kṣīṇaśōṇitamāṁsasya vāyurūrdhvagatiścaran|
ubhē manyē samē yasya sadyō muṣṇāti jīvitam||7||
antarēṇa gudaṁ gacchan nābhiṁ ca sahasā'nilaḥ|
kr̥śasya vaṅkṣaṇau gr̥hṇan sadyō muṣṇāti jīvitam||8||
vitatya parśukāgrāṇi gr̥hītvōraśca mārutaḥ|
stimitasyāyatākṣasya sadyō muṣṇāti jīvitam||9||
hr̥dayaṁ ca gudaṁ cōbhē gr̥hītvā mārutō balī|
durbalasya viśēṣēṇa sadyō muṣṇāti jīvitam||10||
vaṅkṣaṇaṁ ca gudaṁ cōbhē gr̥hītvā mārutō balī|
śvāsaṁ sañjanayañjantōḥ sadyō muṣṇāti jīvitam||11||
nābhiṁ mūtraṁ bastiśīrṣaṁ purīṣaṁ cāpi mārutaḥ|
pracchinnaṁ janayañchūlaṁ sadyō muṣṇāti jīvitam||12||
bhidyētē vaṅkṣaṇau yasya vātaśūlaiḥ samantataḥ|
bhinnaṁ purīṣaṁ tr̥ṣṇā ca sadyaḥ prāṇāñjahāti saḥ||13||
āplutaṁ mārutēnēha śarīraṁ yasya kēvalam|
bhinnaṁ purīṣaṁ tr̥ṣṇā ca sadyō jahyāt sa jīvitam||14||
śarīraṁ śōphitaṁ yasya vātāśōphēna dēhinaḥ|
bhinnaṁ purīṣaṁ tr̥ṣṇā ca sadyō jahyāt sa jīvitam||15||
āmāśayasamutthānā yasya syāt parikartikā|
bhinnaṁ purīṣaṁ tr̥ṣṇā ca sadyaḥ prāṇāñjahāti saḥ||16||
pakvāśayasamutthānā yasya syāt parikartikā|
tr̥ṣṇā gudagrahaścōgraḥ sadyō jahyāt sa jīvitam||17||
pakvāśayamadhiṣṭhāya hatvā sañjñāṁ ca mārutaḥ|
kaṇṭhē ghurghurakaṁ kr̥tvā sadyō harati jīvitam||18||
dantāḥ kardamadigdhābhā mukhaṁ cūrṇakasannibham|
siprāyantē ca gātrāṇi liṅgaṁ sadyō mariṣyataḥ||19||
spr̥ṣṭaḥ prāṇāñjahātyāśu śakr̥dbhēdēna cāturaḥ||20||
vAtAShThIlA susaMvRuddhA tiShThantI dAruNA hRudi|
tRuShNayA~abhiparItasya sadyo muShNAti jIvitam||4||
piNDike shithilIkRutya jihmIkRutya ca nAsikAm|
vAyuH sharIre vicaran sadyo muShNAti jIvitam||5||
bhruvau yasya cyute sthAnAdantardAhashca dAruNaH|
tasya hikkAkaro rogaH sadyo muShNAti jIvitam||6||
kShINashoNitamAMsasya vAyurUrdhvagatishcaran|
ubhe manye same yasya sadyo muShNAti jIvitam||7||
antareNa [1] gudaM gacchan nAbhiM ca sahasA~anilaH|
kRushasya va~gkShaNau gRuhNan sadyo muShNAti jIvitam||8||
vitatya parshukAgrANi gRuhItvorashca mArutaH|
stimitasyAyatAkShasya sadyo muShNAti jIvitam||9||
hRudayaM ca gudaM cobhe gRuhItvA [2] mAruto balI|
durbalasya visheSheNa sadyo muShNAti jIvitam||10||
va~gkShaNaM ca gudaM cobhe gRuhItvA mAruto balI|
shvAsaM sa~jjanaya~jjantoH sadyo muShNAti jIvitam||11||
nAbhiM mUtraM bastishIrShaM [3] purIShaM cApi mArutaH|
pracchinnaM [4] janaya~jchUlaM sadyo muShNAti jIvitam||12||
bhidyete va~gkShaNau yasya vAtashUlaiH samantataH|
bhinnaM purIShaM tRuShNA ca sadyaH prANA~jjahAti saH||13||
AplutaM mAruteneha sharIraM yasya kevalam|
bhinnaM purIShaM tRuShNA ca sadyo jahyAt sa jIvitam||14||
sharIraM shophitaM yasya vAtAshophena dehinaH| bhinnaM purIShaM tRuShNA ca sadyo jahyAt sa jIvitam||15||
AmAshayasamutthAnA yasya syAt parikartikA| bhinnaM purIShaM tRuShNA ca sadyaH prANA~jjahAti saH||16||
pakvAshayasamutthAnA yasya syAt parikartikA| tRuShNA gudagrahashcograH sadyo jahyAt sa jIvitam||17||
pakvAshayamadhiShThAya [5] hatvA sa~jj~jAM ca mArutaH| kaNThe ghurghurakaM kRutvA sadyo harati jIvitam||18||
dantAH kardamadigdhAbhA mukhaM cUrNakasannibham| siprAyante ca gAtrANi li~ggaM sadyo mariShyataH||19||
tRuShNAshvAsashirorogamohadaurbalyakUjanaiH| spRuShTaH prANA~jjahAtyAshu shakRudbhedena cAturaH||20||
The patient of painful and fully manifested vatasthila (hard tumor caused by vitiated vata) in the cardiac region if, suffers from intense thirst, then he instantly dies.[4]
If patient develops laxity in the calf muscles and irregularity in the structure of the nose due to the movement of abnormal vata all over the body, then he instantly dies. [5]
If the eye brows of patient are dislocated (drooped) and severe burning sensation in the body develops, and patient suffers from hiccup, he instantly dies.[6].
Diminution of blood and flesh in a patient, who is suffering from distension of both the manyas (carotid regions of the neck) by the abnormal vata moving upwards leads to death. [7]
If a weak patient develops suffering in the groin region due to sudden aggravation of vata between the anus and the umbilicus, then he instantly dies. [8]
Stretching of the tip of ribs by the aggravated vata afflicting the chest of a patient, whose eyes are dilated and who feels staimitya (as if covered with a wet cloth) leads to instant death. [9]
Congestion/constriction of both heart and anus by strongly aggravated vata in a weak patient leads to instant death. [10]
If a patient develops severe dyspnea due to congestion/constriction of both groins and anus by strongly aggravated vata, he dies instantly. [11]
If a patient develops severe cutting pain in umbilicus, urination, top of urinary bladder, defecation caused by strongly aggravated vata, he dies instantly. [12]
If a patient suffering from pricking pain in the groin region caused by the vitiated vata develops diarrhea and thirst, he dies instantly. [13]
The patient whose entire body is already pervaded by aggravated vata, if suffers from diarrhea and thirst, dies instantly. [14]
The patient whose body is swollen because of vata dominant Shotharoga and suffers from diarrhea and thirst, dies instantly [15]
The patient having cutting pain originated from Amashaya (stomach including the small-intestine) suffers from diarrhea and thirst, dies instantly. [16]
The patient having cutting pain originated from Pakvashaya (large intestine) suffers from thirst and severe anal spasm, dies instantly. [17]
If abnormal vata having its site of manifestation in Pakvashaya (large intestine) causes unconsciousness and develops stertorious breathing (obstruction of breathing by Kapha) in the throat, the patient dies instantly. [18] Appearance of teeth as if adhered with mud, face as if covered with ashes and excessive perspiration, are signs of the patient who will die soon. [19]
Appearance of diarrhea in a patient having thirst, dyspnea, Shiroroga (headache), unconsciousness, debility and groaning sound from the throat are signs of the patient who will die soon. [20]
तत्र श्लोकः-
एतानि खलु लिङ्गानि यः सम्यगवबुध्यते|
स जीवितं च मर्त्यानां मरणं चावबुध्यते||२१||
tatra ślōkaḥ-
ētāni khalu liṅgāni yaḥ samyagavabudhyatē|
sa jīvitaṁ ca martyānāṁ maraṇaṁ cāvabudhyatē||21||
tatra shlokaH-
etAni khalu li~ggAni yaH samyagavabudhyate|
sa jIvitaM ca martyAnAM maraNaM cAvabudhyate||21||
The physician who perfectly comprehends these signs can very well anticipate the survival or death of the patient. [21]
Tattva Vimarsha (Fundamental Principles)
- Excessively vitiated vata can cause immediate death.
- Disorders associated with excessive thirst and diarrhea indicating severe dehydration can cause immediate death.
Vidhi Vimarsha (Applied Inferences )
Fundamental to ensuring quality palliative and end-of-life care is a focus on four broad domains:
- physical symptoms;
- psychological symptoms;
- social needs that include interpersonal relationships, care giving, and economic concerns; and
- spiritual needs
Standardized methods for conducting a comprehensive assessment focus on evaluating the patient's condition in all four domains affected by illness: physical, psychological, social, and spiritual.
Regarding social needs, health care providers should assess the status of important relationships, financial burdens, care giving needs, and access to medical care.
Especially when an illness is life-threatening, there are many emotionally charged and potentially conflict-creating moments, collectively called "bad news" situations, in which empathic and effective communication skills are essential.
Physical Symptoms and Their Management- Great emphasis has been placed on addressing dying patient's pain. Some institutions have made pain assessment a fifth vital sign to emphasize its importance. The most common physical and psychological symptoms among all terminally ill patients include pain, fatigue, insomnia, anorexia, dyspnea, depression, anxiety, and nausea and vomiting. In the last days of life, terminal delirium is also common. Assessment of patients with advanced cancer has shown that patients experienced different physical and psychological symptoms.
The following signs are observed contemporarily that can be related with signs enlisted in this chapter.
Table 1: Signs of Impending Death1[1]
|Physiologic Changes
|Cardiac and Circulation Changes
|Decreased blood perfusion
|Skin may become mottled and discolored. Mottling and cyanosis of the upper extremities appear to indicate impending death versus such changes in the lower extremities.
|Provide good skin care. Turn patient every 2-3 hours if this does not cause discomfort. Lotion to back and extremities. Support extremities with soft pillows.
|Decreased cerebral perfusion
|Decreased level of consciousness or terminal delirium.Drowsiness/disorientation
|Orient patient gently if tolerated and this is not upsetting. Allow pt. to rest.
|Decrease in cardiac output and intravascular volume
|Tachycardia Hypotension Central and peripheral cyanosis and peripheral cooling.
|Comfort measures. Space out activities.
|Urinary function
|Decreased urinary output
|Possible urinary incontinence.Concentrated urine.
|Keep patient clean and dry. Place a catheter if skin starts to break down or if patient is large and difficult to change diapers and linen.
|Food and Fluids
|Decreased interest in food and fluid.
|Weight loss/dehydration
|Do not force fluid or foods.Provide excellent mouth care.
|Swallowing difficulties
|Food pocketed in cheeks or mouth/choking with eating/coughing after eating
|Soft foods and thickened fluids (e.g. nectar) as tolerated. Stop feeding patient if choking or pocketing food.
|Skin may become mottled or discolored.
|Patches of purplish or dark pinkish color can be noted on back and posterior arms/legs.
|Keep sheets clean and dry-avoid paper directly to skin. Apply lotion as tolerated.
|Decubitusulcers may develop from pressure of being bedbound, decreased nutritional status.
|Red spots to bony prominences are first signs of Stage I decubiti and open sores may develop.
|Relieve pressure to bony prominences or other areas of breakdown with turning and positioning Q2 hrs if tolerated. If patient has increased pain or discomfort with position changes, decrease the frequency.
Special mattress as needed.Duoderm or specialized skin patch to Stage I-II ulcers. Change Q5-7 days or as needed. Goals of wound care for Stage III and IV decubiti should be to promote comfort and prevent worsening rather than healing since healing most likely will not occur.Consider application of specialized products such as charcoal or metronidazole paste (compounded) if odor present.
|Retention of secretions in the pharynx and the upper respiratory tract.
|Noisy respirations - usually no cough or weak cough.
|Head of bed up at 45 degrees. Can fold small soft pillow or towel behind neck for extra support.
|Shortness of breath
|Oxygen at 2-3 liters may help for some patients and often helps families to feel better. Link to Dyspnea module
|Cheyne-Stokes respirations
|Notable changes in breathing.
|A gentle fan blowing toward the patient may provide relief.Educate families that this is normal as the patient is dying.
|General changes
|Profound weakness and fatigue.
|Drowsy for extended periods. Sleeping more.
|This is normal. Educate family.
|Disoriented with respect to time and a severely limited attention span.
|More withdrawn and detached from surroundings. May appear to be in a comatose-like state.
|This is normal. Educate family.
|Patient may speak to persons who have already died or see places others cannot see.
|Family may think these are hallucinations or a drug reaction.
|If patient appears frightened may need to treat with medication. Otherwise, educate family that this is normal and common
- ↑ Transition to Death - End of Life Curriculum - Stanford University; http://endoflife.stanford.edu/M06_last48hr/signs_imp_death.htm


text:
Durham University student's Olympic call-up
Durham University student and rowing cox Lily van den Broecke has been selected to represent Team GB at the London 2012 Paralympic Games.
Lily's selection comes only a couple of weeks after winning Gold at the Munich World Cup with her crew.
The 20-year-old is a first year student at Durham University, she started rowing at secondary school. After four years of sculling, she tried out as a cox and found it suited her. She splits her time between rowing and studying a degree in Philosophy, Politics and Economics.
Although Lily has been selected for the Paralympics, she is able-bodied. The rules do not preclude able-bodied athletes to compete as rowing coxes in the Paralympics.
"I'm beyond excited to be part of the Paralympic Games. Not only is it an honour to be coxing some top athletes but the experience will be made even more special when shared with our home nation."


text: Sliding scale is a way to adjust the amount of insulin you take based on your current blood sugar. I do it like this. (Blood Glucose) less 100 divided by 50. So in other words, for every 50 mg/dL I am above 100, I take 1 extra unit of insulin with my before meal insulin dose. Most doctors write it out, for example, blood glucose of 100 to 150, add 1 unit of insulin extra ( or take 5 units total). Something like that. And I get a little fancier. Before 9 AM, I divide by 40, after, I divide by 60. This is more suited to my body, which seems to be a little insulin resistant in the morning, and less so in the afternoon. As for the One Touch, I use the Profile. All of the strips for all of the meters are prohibitively expensive. And they all run about the same, for the most part. Around $60 for 100 strips. This of course varies by sales promotions and store. But I would guess that is about average. I love the profile - you can use it to store more info than just blood sugars. It will store the type and amount of insulin dose, in tenths for a bolus, in whole numbers for MI. It will also store carbs. I don't think all this is download-able at this time, but I feel that there is a program in developement that would allow you to download this info onto your computer. At this time, you can at least download the blood sugars. Many meters have that option - but none of the others has the capapbility to manage data like the Profile. I really like it. : ) Good luck!


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When Moses went to Mount Sinai more than 3,000 years ago, he came back with 10 commandments. When the world's presidents and prime ministers go to New York City in late summer, they will go back not with 10 commandments but 169.
Too many? Some people certainly think so.
"Stupid development goals," the Economist said recently. It argued that the 17 sustainable development goals and roughly 169 targets should "honor Moses and be pruned to 10 goals." Others disagree. In a report for the Overseas Development Institute, May Miller-Dawkins warned of the dangers of letting practicality "blunt ambition" and backed SDGs with "high ambition."
The debate over the "right" number of goals and targets is interesting, important even. But it misses a key point: No matter how many goals and targets are finally agreed, if we can't measure their real impact on people's lives, on our societies and on the environment, then they risk becoming irrelevant.
Unfortunately, we already know that many developing countries have problems compiling even basic social and economic statistics, never mind the complex web of data that will be needed to monitor the SDGs. A few examples: In 2013, about 35 percent of all live births were not officially registered worldwide, going up to two-thirds in developing countries. In Africa, just seven countries have data on their total number of landholders and women landholders, and none have data from before 2004. Last but not least, we are not sure if we have a billion people living in extreme poverty worldwide, half a million or more than a billion due to fast-changing economies and associated measurement challenges.
Why does this matter? Without adequate data, we cannot identify the problems that planning and policymaking need to address. We also cannot judge if governments and others are meeting their commitments. As a report from the Center for Global Development noted, "Data ... serve as a 'currency' for accountability among and within governments, citizens and civil society at large, and they can be used to hold development agencies accountable."
So data matters. Despite this, blank spaces persist in the statistics of many developing countries. And they persist even at a time when the world is experiencing a "data revolution" — a rising deluge of data matched by ever-increasing demand for data.
Despite the challenges, we are optimistic all countries, including the poorer ones, can make quick, dramatic progress.
Firstly, there is not only a growing awareness of the statistical challenges they are facing but also a growing willingness to do something about it. Some statistical offices in more than 30 developing countries have signed up to our Data Declaration, in which they state that "the time is now to bring the data revolution to everyone, everywhere."
Second, new technologies are already helping to revolutionize the world of data. The Innovations Inventory of the Partnership in Statistics for Development in the 21st Century, or PARIS21, has compiled hundreds of ways in which technology is making it easier and less costly to collect data and providing new sources of data, like "big data." Examples abound, including initiatives from nongovernmental organizations and private sector.
In the frame of its Data for Development challenge, Orange Senegal opened up its mobile phone call log data for researchers to generate insights into health, transportation, demographics, income inequality and more. Another truly "Big Idea" comes from Restless Development, a youth-led development agency that equips young people with knowledge, skills and platforms necessary to effectively interpret data in order to mobilize citizens to take action.
Third, we are optimistic because we want to build on what is already there — existing national statistical systems.
Clearly, many are far from ready to join the data revolution. One of our colleagues recalls visiting one national statistical office that couldn't pay its power bill and had to negotiate with a neighbor to string an extension cord from his home to the office. That may be an extreme example, but other challenges — including technology gaps, shortages of trained staff, weak data dissemination and poor relations with users — are all too common.
Nevertheless, national statistical agencies are the only entities with the expertise and legal frameworks to play the lead role in collecting, processing and disseminating data. It is on them that the data revolution for development for sustainable development must be built.
Of course, our Road Map for a Country-led Data Revolution is only a start. Much else needs to happen. This includes designing pilot projects, finding better ways to integrate new sources of data in existing national systems and — unsurprisingly — finding extra funding.
But here again we are optimistic. We don't accept that the cost of monitoring the SDGs will be "crippling." With our colleagues in the U.N. Sustainable Development Solutions Network, we have calculated that additional donor funding of $200 million a year, matched by a similar rise in domestic funding, would enable the 77 countries under the World Bank's International Development Association to successfully monitor their progress on the SDGs — yes, even the proposed 17 goals and 169 targets.
We don't yet know if that will turn out to be the final number of SDG "commandments." But here's something we do know: Developed and developing countries are on the cusp of a huge and dramatic change in how they collect and disseminate data. With the aid of a clear road map, strong political will and "miraculous" technologies, we really are much closer to the promised land of better data than we realize.
Join the Devex community and access more in-depth analysis, breaking news and business advice — and a host of other services — on international development, humanitarian aid and global health.


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5 Things VMware Should Do In 2013
VMware's vision of the software-defined data center is still a long ways off and hard to achieve, but these steps will take it closer to its goals.
In 2012, VMware accomplished a lot by sketching out a vision of the software-defined data center as the direction it's headed. It sees virtualization not as the one-time technology transition early implementers expected, rather as an ongoing process of applying more automation to all forms of data center operations. Despite the heavy R&D such a vision demands, VMware is on a path to grow revenue at a rate of nearly $1 billion a year. At the end of 2011, it had revenue of $3.77 billion, and it was on course to achieve $4.5-$4.6 billion in 2012. Its rate of growth -- 20% -- was slowing, but still healthy in the third quarter of 2012. If that growth can be sustained, VMware is well down the path toward becoming one of the giants of the technology industry. In the coming year, the reach of VMware's goals will require it to juggle some possibly conflicting options and act on key issues to maintain its momentum. Here are five suggestions for how VMware should proceed.
1. Offer Hypervisor Performance Information (Users: Don't Hold Your Breath)
We need more benchmark information on ESX Server hypervisor performance, even though "performance" isn't the only consideration in installing virtualization. The general virtual machine (VM) management environment is certainly as important as baseline performance. Still, efficient execution of tasks is a leading attribute of software, with varying capability often hidden in a set of similar but competing products. If Microsoft, Citrix or Red Hat can claim a performance advantage over ESX Server, it will speed up the painfully slow inroads they've made in VMware's customer base. I suspect the leading hypervisors aren't that far apart when it comes to performance. Some testing indicates that, while other testing shows performance gaps. Read full story on InformationWeek
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Eden Sassoon left The Real Housewives of Beverly Hills last year after filming just one season of the show. Eden revealed that she was a recovering alcoholic but she didn't get much sympathy from her co-stars. Of course, alcohol has played a huge part of the show for years, as Kim Richards' problem with alcohol was exposed on the very first season of the show. But Eden probably didn't expect to be yelling at her co-stars and flipping out on Lisa Rinna while filming. Even though Sassoon left the show because she didn't want the stress in her life, she is still watching the show. Eden keeps saying that she wants nothing to do with the show and the materialistic women, she is still tuning in for The Real Housewives of Beverly Hills and tweeting about it.
According to a new tweet, Eden Sassoon is now sharing her thoughts about the new women on the show and she seems to think that Dorit Kemsley may have a drinking problem. As it turns out, Eden believes that Dorit should slow down on the drinking as it isn't good for her. In addition, Eden reveals that she thinks the ladies are too materialistic and she doesn't understand why the ladies and Bravo keep spending so much money on things.
"Nice to see Dorit is still drinking more than she should. I said it! #rhobh Oh and Kyle get a grip, she drinks [too] much!" read one of the tweets that Eden Sassoon shared on Twitter while adding later, "Thank you… I'm just having a moment / it's truly shocking this is what #bravo spends $ on. Mindless nonsense."
Sassoon also made a comment about Erika Girardi's spending, revealing that she thought it was completely outrageous that Erika was spending her money. It's clear that Eden has plenty of opinions about her former Real Housewives of Beverly Hills co-stars. It is odd that someone is spending so much time slamming her former friends for a show that she chose to film herself last year. In addition, some people believe that she's jealous that she was not on this season of the show, as she seemingly can't let go. Eden stands firm in her claims that she wants to stay far away from the franchise.
Eden Sassoon only filmed one season of The Real Housewives of Beverly Hills before leaving the show behind. It's possible that she will never return to the show, as her comments on social media could be burning every bridge with her former co-stars.


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ThisIsHorosho – Кибер-Ñщер Щ_Щ [Cyber-Lizard]
The Accurate Source To Find Quotes To ThisIsHorosho – Кибер-Ñщер Щ_Щ [Cyber-Lizard]."
[ThisIsHorosho – Кибер-Ñщер Щ_Щ [Cyber-Lizard]]
[Stas Davidov] Source: LYBIO.net
Sup I'm Stas Davidov! First vid was sent by Kasia! More than a million views in a couple of days. And I'm telling you, this is a sight to see! [here's a cross]. A lizard playing a game on a smartphone! [go cs?]. Planet of Apes, you say? Planet of Apes, you say? Planet of Lizards! Today he's killing digital ants [today you spilled a beer…] Tomorrow – the real thing! Wait, lizards do eat real ants. [or die tryin'] I lick the screen just like that when i watch german movi… Oh, did that came out loud? [busted!] They better not make a game where beer crawls like that [way to change the topic!]. I'll chew thru my new iPad. Luv it how the lizard looks at the screen and goes like hmm, those guys are tastless [i.e. they don't taste like anything]. I think i'm being deceiv… MOAR ANTS. Tastes like video game? [like screen]. Scumbag owner. Reptile hungry – feed him games! If you can play WoW all day and not eat [not eat skill +6] doesn't bloody mean the animal is happy with it. And move him away from the screen! Or do you want him to become the first lizard on earth who wears glasses? [firstlizardonearthwhowearsglasses]. And what the hell's with the game? Why aren't the physiological characteristics of players taken into account? [respect my animal chracteristics!]. I will fight for lizard rights! Why can't you eat wasps? [or bumblebees] Ok, enough of PETA for one day. Instead lemme tell you how this lizard is called Bearded dragon! YO DRAGON! SHAVE!
strong>[Stas Davidov] Source: LYBIO.net
And this is Horosho! A vid for "tips for winter exams†section was sent by jerrykve. [In Russia there is a chance to get your final grade without taking the final exam, if you're an exceptional student. This practice is called "getting an auto-gradeâ€. It is also called a "machine-gun gradeâ€, hence the machine-gun.] [Elena Ivanovna, I'm a machine-gunner]. [And here's my machine-gun! Can i have a machine-gun grade?]. Gentlemen, place your bets! Either he didn't put the uniform in vain and will get his auto-mark [door No. 1] [door No. 2] Or he didn't put the uniform in vain coz the next year he'll have to wear by the law [you're in the army now!] Now we'll find out! [you win]. What can i say, nailed it! [do not try this at home] Let's just hope it's not med school and he's not a future doctor [stomatologist]. On second thought, teacher would be unwise not to understand the hint of the gun on her table. [Here's my machine-gun]. [kill me] So, cunning is his main weapon. Get it? WEAPON! I think if he went to a bank like this, he'd get an auto-grade as well. [I'm a machine-gunner] Hey, i know another great way! It's more reliable [and more common] Grade me a 5 (A)! Here's my five! Or you go to the union and say I wanna be a member! Here's my… Did i say that out loud as well? [naaaah] I feel universities will be overflown by those machine-gunners. Just watch out, talk it out so you won't gather an army of classmates. [imagine everyone a machine-gunner] All in all, he's lucky. You know how it goes: A for creativity, F for the subject.
strong>[Stas Davidov]
And this is Horosho! Third vid is sent by tolstovsanya. And once again it's about ruthless taekwondo! [taekwondo again]. Of course, everyone would like that. But the reality is cruel! [MOAR CRUEL]. [take that]. [and this!]. [didn't expect that, now did ya?]. [bang! a round kick!]. Too much violence in this video! Continue without me [Stas went to look at kitty pics]. [watching without Stas ) ] Teletubbies learned taekwondo? [ohno, he's back!]. Oh those korean kids. What's the matter? Didn't eat a dog in the morning? [koreans do that, right?]. There's what's bugging me. 2011. Korea, country that just released the Galaxy Note! WHAT'S WITH THE QUALITY? [WUT?!]. ARE THEY TAKING A VID ON A HAM SANDWICH??? [before-revolutionary tech]. Can't even see trainer's ass in the mirror! [voyeur much]. [trainer's ass 🙁 ]. Those dangerous round kicks!. Had at least one reached it's target – the whole hall would be destroyed! [Falcon punch!]. And little korean kids are prolly shouting something like kick his asian butt [butt]. "we wanna see his liver!†[ass]. But don't worry, kids are on the light side. The winner is… Friendship! [is magic ;] ]. So jumpy! Their master must be a kangaroo [drunken kangaroo style] Hmm, here's an idea!
strong>[Stas Davidov] Source: LYBIO.net
And this is Horosho! And the question was sent to us by greeneyeser. There sits an old man, wearing a hundred coats. He who undresses him – … ? There sits an old man, wearing a hundred coats. He who undresses him – … ? Leave your interesting comments here on Youtube! That's all folks, I'm Stas Davidov. Subscribe, click "like†and send your videos here [thisishorosho.ru] to the "Ðа Обзор†section. So, how will you celebrate New Year? Gather some friends, get drunk, bring the house down. Well everything The Sims will allow me. end polska hotel =) NEW YEAR – FRIENDSHIP – PSHE! P.S. going to Poland to get wasted, learned polish cursewords) My!
ThisIsHorosho – Кибер-Ñщер Щ_Щ [Cyber-Lizard]. Leave your interesting comments here on Youtube! That's all folks, I'm Stas Davidov. Subscribe, click "like†and send your videos. Complete Full Transcript, Dialogue, Remarks, Saying, Quotes, Words And Text.


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20,000 rally in Italy against anti-gay, anti-abortion and anti-feminist conference
An estimated 20,000 people have protested in Verona against a conference which has brought a global network of anti-gay, anti-abortion and anti-feminist activists to the northern Italian city.
The hosting of the World Congress of Families (WCF), a US coalition that promotes the values of the Christian right, has been especially contentious in Italy as it is supported by the far-right League, a partner in the country's coalition government. Matteo Salvini, the party's leader and Italy's deputy prime minister, spoke at the event on Saturday evening.
Continue reading…
Read More Christian right summit in Verona draws massive protest


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When winter temperatures get below freezing, it's a far cry from our familiar sweltering, southern summers. Here are some cold weather health and safety tips to ease the freeze in South Mississippi!
Stay Hydrated– While it may be tempting to use coffee or hot tea as your winter go-to beverage, reach for water first! Staying hydrated during the winter can reduce dry skin and flush the toxins out of your body to reduce chances of getting the cold or flu.
Layer Up– Instead of wearing one heavy layer, wear several layers of loose-fitting and lightweight warm clothing, and make sure that your outer layer is windproof!
Wear a Hat– Up to 50 percent of your body heat can escape from an uncovered head when temperatures are below freezing. Wearing a hat when outdoors will help your body retain heat. If your children walk to school, make sure they have a hat to keep their head warm!
Check on Your Elderly Friends and Neighbors– Make sure that they have adequate heat, food and water. The elderly are particularly prone to cold-related illness.
Heat– The American Red Cross suggests using a three-feet rule when using a space heater. Place it on a level, hard surface and keep anything flammable at least three feet away – things such as paper, clothing, bedding, curtains or rugs. Also remember to never use your oven, stove or grill as a source for indoor heating.
Install and Maintain a Carbon Monoxide Detector– Carbon Monoxide (CO) is an odorless, colorless and tasteless gas that is created from burning fuel, such as with oil or gas furnaces, fireplaces, stoves, and some space heaters. CO prevents your body from using oxygen, which can cause damage to the heart, brain, and other organs, and eventually lead to death. If your devices are not properly installed or cleaned and serviced regularly, they can be a source of CO exposure.


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July 9, 2019
Tobacco Economics Research Run Down at Vietnam Economics Annual Meeting
Some of the best moments of our work are those where we have the opportunity to meet with our partners face-to-face and see them present their research to a broader audience. A few weeks ago at the 11th Vietnam Economists Annual Meeting (VEAM)—hosted by our partner in Vietnam, DEPOCEN—we were able to do just that.
The conference was jam-packed with productive discussions not only on tobacco, but also environment, trade, sustainable development, and alcohol taxation, just to name a few. During the sessions on tobacco, research presentations were delivered by our partners—DEPOCEN, and the Institute for Public Policy Management (IPPM) at the National Economics University of Vietnam. In addition, other Tobacconomics partners from Pakistan presented their research findings.
Some notable highlights—Nguyen Ngoc Minh from DEPOCEN discussed her research on the crowding-out effects of tobacco expenditure in Vietnam, and their analysis was developed using the methodology from our recently released Tobacconomics Toolkit on Using Household Expenditure Surveys.
Rijo John, an India-based Tobacconomics consultant and global expert in tobacco economics, shared his research on the economic costs of diseases and deaths attributable to bidi smoking in India in 2017. According to John, "85% of smoking in India is from smoking bidis…the total economic cost from bidi smoking is about 12.5 billion USD, while excise tax revenues from bidis is only about 60 million USD." Meanwhile, bidis are very cheap in India, costing only about Rs 4 on average. Additionally, taxes comprise only around 9% of the retail price. John's research identifies an important area where policy intervention is necessary to curb the staggering costs of tobacco use—especially bidis—in India.
Muhammad Nasir from the Pakistan Institute for Development Economics (PIDE) presented the findings from their most recent report on behavioral responses to tobacco taxation. The research found that reverting back to a two-tiered tax structure, if set at 2017 rates, would lead to increased revenue, and recommended that the funds be earmarked for improving healthcare programs.
The Social Policy and Development Centre's (SPCD) report also showed that the data directly contradicts the tobacco industry's argument that it contributes significantly to the economy of Pakistan. According to the report, tobacco represents only 0.42% of the total value of crop sector, and only 0.03% of agricultural employment. Additionally, the share of cigarette production in industrial output is only 1.1%.
It's noteworthy that a few months after the release of the PIDE & SPDC reports, further consultations with the government, along with the concerted efforts of the tobacco control community, the government reverted to the two-tiered structure. Although the impacts have yet to be measured, this move is a step in the right direction and evidence of solid research informing better tobacco tax policies in Pakistan.
Immediately following VEAM, we had the opportunity to host our 2nd annual UIC Asia Partners Meeting. Stay tuned next week for another blog post, where we will be discussing more details about the meeting and a few exciting announcements!


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5d VR
5dVR -, Al Qāhirah, EG
About Us
A digital studio based in Cairo, pioneering the creation of absorbing VR/AR experiences.
We deliver immersive digital realities that result in total emotional engagement. That is the value of this technology.
The platforms and creative content we provide deliver total immersion and an unforgettable experience.
We've been creating AR solutions since 2011, and introduced VR into the regional market in 2014. We're fans of and fanatical about digital reality. Our name, the Fifth Dimension, comes from our belief that VR is such a disruptive technology it's in fact a new dimension for human experience. Space and time have become variables at our command.


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Rejection isnвЂt straightforward to take , however dishing it out is no cakewalk both. My dad gave me wonderful recommendation once I was youthful and dating. He said it's good to be with someone beautiful russian women who brings something to the desk, " meaning a relationship is not one sided. If its your girlfriend, ask her what shes sporting and if she doesnt point out her lingerie which she could not with out a bit of coaxing, ask about her lingerie and also the color. A perfect begin.
In case your purpose isn't to turn her on, but to get out of the good friend zone" (as an instance she's a pal or coworker), there are issues you possibly can say with texts to make her assume you is likely to be more than just a buddy. Do not be afraid to poke enjoyable at her. Teasing her somewhat beautiful russian women exhibits that you're assured in yourself and can assist construct attraction between the 2 of you. Equally, it's also a good idea to make enjoyable of yourself. This may make her snicker, speak in confidence to you, and make her feel comfortable around you.
HowStuffWorks particulars how the world works. Dating is part of the world, so clearly it's coated right here. The category is not completely centered on men and questions they russian women will have, but most of the entries are about wooing women. These listicles present an excellent introduction to dating advice.
Clothes must be fitted, youthful and modern. It is important that your model is up-to-date and not harking back to a long beautiful russian women time previous. Don't look like you probably did while you have been just beginning out in your favourite oversized football jerseys.
Within the months he was gone, although, I discovered myself lacking his whimsical way of living, the way he may make associates with everyone. Most of all, I just missed us. I began therapy and realized that by not being clear about what I really beautiful russian women needed, I used to be actually supporting much of Jimmy's conduct. I began to wonder if he could refocus his priorities and, if we pitched in collectively on our relationship, whether we would have the ability to make it work.
It is important to take the view that modifications to sex life and sexual functioning are regular and may be constructive. What happens in the menopausal period doesn't matter so long as each partners are happy. Attempt to discover new methods to display beautiful russian women affection and intimacy that make each of you feel fascinating. For some couples, that may mean placing penetrative intercourse on maintain and just kissing and cuddling for a while, or spicing up your intercourse life with sexual enhancement merchandise like dildos, lubricants and erotic movie or literature.
Drawback: #1. Following my declaration that i did like her, she appears much less involved (i understand this is typically the case, which is why you advise not revealing too much russian women). I did nevertheless really feel enough time had passed and she was giving me each indication she was totally digging me.
A Guide To Effortless Secrets In Beautiful Russian Women
We often go 3-6 months, even 8 months every now and then, between sex. She's very engaging – I tell her so, yet she will not undress in front of me. She has not touched me intimately in several years. By no means. When intercourse does happen, it is all me. My wife has never initiated a sexual encounter (aside beautiful russian women from a uncommon occasion when she was very intoxicated – which actually gave me some false hope). She never engages in foreplay, by no means. She does not contact me, she does not even hug me during intercourse (which AT ALL TIMES must be in our mattress, missionary place). I've to beg and plead for sex. It's exhausting and humiliating.
Significant Factors In Russian Women – The Options
Choosing No-Fuss Systems In Russian Women
If you happen to're feeling distant from your associate, you might suppose that placing on a horny dress or doubling up on your periods within the weight-room is one of the simplest ways to get his or her consideration and leap-begin your flagging romance. And that will worknevertheless it could additionally backfire: "If he or she would not read your thoughts or discover that you just're attempting to impress him or her, you russian women may find yourself feeling worse and resentful," says Solomon. Instead, Solomon suggests sitting down to speak honestly about how you are feeling. "Say one thing like, 'I don't feel particularly connected to you proper now, and I have some ideas about what I might love to do otherwise to make us really feel nearer,'" she says. "That means, it's much less of a check that your accomplice passes or failsyou are in it collectively, and you're both making an effort.


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Parenting in Abstract: Naming a Person
I think a lot of people get excited to name babies. Like they do naming a puppy. When it arrives, it'll be small and (hopefully) cute and as creator of this being, you get naming privileges.
Similar to if you had just discovered some new kind of ant.
Naming RAD was probably one of the most challenging things to happen to my and Kerstyn's marriage. She was happy with lots of names. Found them cute or classic. Empowering or fierce.
I, on the other hand, hated all of them.
We had quickly picked out a boys name. The day before we found out we would be having a girl. Needing to start over, it took us weeks to narrow down a new list. We searched through everything.
- Literary names
- French names
- Irish names
- Popular names
- Unpopular names
We had friends mediate suggestion time. Mostly so I could be subdued into tolerating more options, but also for my stubbornness to not thoroughly discourage Kerstyn. But after many long and trying hours we finally pinned it down.
Clearly, I was the problem through this process. I like to be particular and precise which made it hard to conceptualize a name for a person that didn't exist yet. In addition to that, I just plainly didn't like a lot of the names we looked at.
Many were too frilly or flowery. If I wasn't able to easily spell or pronounce it, it was a no. And the one that was likely most annoying was if there was already an existing person that my brain made an active connection to. I didn't like the idea of using a family name – both our families are too large and too close to pick just one or two in order to carry down a name. Some sounded to old or too basic. I disliked A LOT of names.
The part of the naming process that was most important to me though, was making sure we named a PERSON and not a BABY. I wanted her to have a name that people couldn't make assumptions on. Something that didn't impose a preconceived identity on her. A name that didn't just imply how cute she was when she was 2-feet tall. I needed it to persevere to when she was 12, 25, 48 and 91.
Ultimately, I think we found it. All the lists and strife and struggle produced something I think we are both pretty happy with. It's unique and her own (trust me, I googled it). So now, in just a few short weeks, the world will welcome the one-and-only Regan Amelia.


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The biggest chefs on TV seek out and cook with a wide variety of unusual and rare ingredients from around the world but when they go home at the end of a long day, what would you find in their personal refrigerators? You might be surprised to discover that their top essentials are more common than you think.
Watch: See What's Inside Celebrities' Refrigerators


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Loftin's new position focuses on connecting faculty with research opportunities
R. Bowen Loftin: "People seem to think I'm doing nothing, which is totally false. I've been very busy since all this happened back in November."
R. Bowen Loftin: "People seem to think I'm doing nothing, which is totally false. I've been very busy since all this happened back in November."
MU spokesman Christian Basi: "AAU status would not be directly affected by any cuts to our budget. However, in the long term, it could be difficult to maintain some of the areas that support our high quality research and teaching."
Schaefer said he wants to see faculty workload considered as a factor to determine if MU is improving its AAU ranking.
The slates address a variety of issues from increasing affordability in housing and dining to advocating for mental health and social justice issues to better the lives of MU students.
Of the 78.8 percent of female victims of penetration by force, 61 percent did not believe the incident was serious enough to report.
Over one-third of MU senior women have experienced unwanted sexual contact while at MU.
Almost one-third of MU senior women have experienced unwanted sexual contact while at MU.
Faculty say the "culture of modesty" limits potential to win awards.
The retirement of 110 tenured faculty provides MU a rare opportunity to rethink diversity and its priorities during the hiring process.
A council survey found faculty, on average, believe the raise process isn't fair and does not improve faculty morale.
Representing all faculty members and improving all areas of MU academics should be the future provost's main goals.
Several faculty members expressed concern that AAU metrics are not representative of non-STEM departments.
Wiencek is currently the interim provost of the Virginia Commonwealth University.
Basi said the UM System and MU currently estimate to spend about $10 million in buyouts.
Jorgensen is the third dean to announce his retirement this year.
The partnership would allow MU to sidestep the formal bidding process for defense contracts.
W. Dudley McCarter said alumni support is essential to MU's membership in the AAU, and hopes to create a new student-recruiting system to gain additional alumni support.
Delafontaine has 37 years of experience in both clinical work and education.
The MU Strategic Operating Plan could be essential for MU to maintain its membership in the Association of American Universities.
Hiring John Boyer, a member of the National Academy of Sciences, has improved MU's membership standing score in the AAU by 12.5 percent.


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'The Nutcracker and the Four Realms' is an overdone Christmas flick [Movie Review]
Not even the star power of Morgan Freeman, Helen Mirren and Keira Knightley can save this predictable and boring film
Not even the star power of Morgan Freeman, Helen Mirren and Keira Knightley can save this predictable and boring film
If you're up for some blinged up Christmassy comfort, you could do worse than The Nutcracker and the Four Realms, directed by Lasse Hallstrom and Joe Johnston, but you'd have to try very hard.
Clara Stalhbaum (Mackenzie Foy) is miserable because her mother died and her father is forcing her and her siblings to attend a ball on Christmas Eve. Before they head to the ball, he gives each of his children a gift from their late mother. Clara's is a large egg ornament that needs a key to unlock it. The key is missing, despite her mother's note saying that all she needs is in the gift.
Clara goes in search of the key.
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There's lots of eye candy to keep the audience entertained while the plot slides down a rabbit hole, er, I mean a tree trunk, to take Clara into a magical kingdom.
CGI wonder and wizardry just can't save the basic need for an original plot, good dialogue, and something, anything, that challenges the audience. Yes, there is a stellar cast, including Morgan Freeman, Helen Mirren and Keira Knightley. Jayden Fowora-Knight glows in the role of Philip, the loyal nutcracker soldier.
But, we're never, ever in doubt about how the story will end. So every slip of a foot from a rock over a raging waterfall, every drop off a precarious cliff does nothing to get out of the "ho hum, seen it before" realm. Sure, it's whimsical and fun, so it gets a star for trying.