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Rain in Ooty :
The rain started Monday evening to Tuesday morning, Ooty registered 24.60mm of rain, many people not going to tourist places. all are stay in hotels mostly due to the rain.
Category Archives: Ooty Tourism News
Ooty Police introduce parking space
Ooty Police introduce Car parking space in Commercial Road to the Mariyamman Temple Street
The new parking space in ooty can accommodate 15 cars and is located just away from the market,
The Nilgiris district police arranged parking space for troubles of both Ooty residents and tourists, near by Ooty Municipal Market,
Ooty police learned that many of the new car parking space, along the market and near Commercial Road.
Parts of Ooty declared 'No Selfie' Zones
Parts of Ooty declared 'No Selfie' zones
Banned clicking selfies in 8th tourist spots in Nilgiris, for ensure the safety of students.
1. Doddabetta Peak
2. Ooty Lake
3. Pykara Lake
4. Coonoor ( Lamb's Rock )
5. Dolphin's Nose
6. Gudalur ( Needle Rock View Point )
7. Valley View
8. Mudumalai (Tiger Reserve).
Dinosaur Park Photos Ooty
Autumn festival Ooty
The 10-day yearly autumn festival, denoting the second season in Ooty began today. Flower show is the real fascination of the celebration, where about two lakh blossom plants of in excess of 50 species are on display.Dance, dramatization and music projects would be composed amid the celebration, to stamp the International Tourism Day on September 27.
10 Popular spots in Ooty to see in 2 days !
- Botanical Garden – Big Garden with Variety of Plants and Flowers
- Ooty Lake – Most visited place in Ooty
- Doddabetta – Best place to see the views of nilgiri hills
- Rose Garden – See the variety of roses here
- Nineth Mile or Shooting Point – Large area of greenery to sit and relax
- Pykara Lake – Another lake to enjoy boating
- Mudumalai – Jungle Area to enjoy safari and wildlife
- Mountain Train – A classic train journey in the mountain
- Wax Museum – Small but interesting place
- Kalhatty Waterfalls – Little faraway spot, best to see in august / september
Ooty is among top 10 long weekend destinations for Indians
Ooty is among top 10 long weekend destinations for Indians. This is found by a survey conducted by popular travel portal "HolidayIQ"
Andaman and Nicobar Islands


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subset: commoncrawl


text: Epidermolysis Bullosa and Chronic Wounds: A Model for Wound Bed Preparation of Fragile SkinPope, Elena MD, MSc, FRCPC; Lara-Corrales, Irene MD, FRCPC (Derm); Mellerio, Jemima E. BSc, MD, FRCP; Martinez, Anna E. MBBS,MRCP,MRCPCH; Sibbald, Cathryn RPh, BScPhm, ACPR; Sibbald, R. Gary BSc, MD, MEd, FRCPC (Med) (Derm), FACP, FAAD, MAPWCA, for the EB International Consensus PanelAdvances in Skin & Wound Care: April 2013 - Volume 26 - Issue 4 - p 177–188 doi: 10.1097/01.ASW.0000428864.72412.b7 FEATURES: CLINICAL MANAGEMENT EXTRA Free SDC CE Abstract In Brief Author InformationAuthors Article OutlineOutline Article MetricsMetrics PURPOSE: To enhance the learner's competence with information about a wound bed preparation model of fragile skin for patients with epidermolysis bullosa (EB). TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Differentiate between the types and subtypes of EB. 2. Apply EB assessment and treatment strategies to patient care scenarios. ABSTRACT Epidermolysis bullosa (EB) is a group of inherited diseases with 4 subtypes. This disorder is a model for fragile skin, with some affected individuals having chronic, difficult-to-heal wounds. The care of wounds in people with EB can be guided by the Wound Bed Preparation paradigm. The treatment of chronic EB wounds is outlined with a quick reference guide of 12 consensus recommendations created by a panel of 11 experts. These recommendations were reviewed by a computer-facilitated modified Delphi process where 15 external reviewers (68.8% of whom reported having 11 or more years' experience with EB care). Inclusion of recommendations was contingent on 80% agreement from reviewers. This continuing education activity will help clinicians identify and treat epidermolysis bullosa and its subtypes. Elena Pope, MD, MSc, FRCPC • Head Section of Dermatology • The Hospital for Sick Children • Toronto, Ontario, Canada Irene Lara-Corrales, MD, FRCPC (Derm) • Assistant Professor of Pediatrics • University of Toronto • Toronto, Ontario, Canada • Pediatric Dermatologist • Interdisciplinary Clinic, The Hospital for Sick Children • Toronto, Ontario, Canada Jemima E. Mellerio, BSc, MD, FRCP • Consultant Dermatologist and Lead for the Adult Epidermolysis Bullosa Service • St John's Institute of Dermatology, Guy's & St. Thomas' NHS Foundation Trust, and Great Ormond Street Hospital for Children NHS Foundation Trust • London, United Kingdom Anna E. Martinez, MBBS, MRCP, MRCPCH • Consultant Pediatrician and Clinical Lead for the Pediatric Epidermolysis Bullosa Service • Great Ormond Street Hospital • London, United Kingdom Cathryn Sibbald, RPh, BScPhm, ACPR • MD Candidate 2013 • University of Toronto • Toronto, Ontario, Canada R. Gary Sibbald, BSc, MD, MEd, FRCPC (Med) (Derm), FACP, FAAD, MAPWCA, for the EB International Consensus Panel • Professor of Public Health and Medicine • University of Toronto • Toronto, Ontario, Canada • Director • International Interprofessional Wound Care Course & Masters of Science in Community Health (Prevention & Wound Care) • Dalla Lana School of Public Health • University of Toronto • Past President • World Union of Wound Healing Societies • Clinical Editor • Advances in Skin & Wound Care • Ambler, Pennsylvania Acknowledgments: This article is dedicated to all persons suffering from epidermolysis bullosa in an attempt to improve their quality of life. The authors thank the late Alex Melkic and Deanna Molinaro from whom we have learned so much and Mölnlycke for their unrestrictive educational grant support. Dr Pope has disclosed that her institution received an unrestricted educational grant from Mölnlycke Health Care to host the EB International Consensus Panel. Dr Lara-Corrales has disclosed that The Hospital for Sick Children is a recipient of grant/research funding from the Canadian Dermatology Foundation Society of Pediatric Dermatology. Dr Mellerio, Dr Martinez, and Dr C. Sibbald have disclosed that they have no financial relationships related to this article. Dr R.G. Sibbald has disclosed that he is a board member of Coloplast, Covidien, J & J (Systagenix), Mölnlycke, Registered Nurses' Association of Ontario, Hollister; and was a board member of 3M, BSN Medical, Gaymar, KCI, and Healthpoint Biotherapeutics; he was a member of the speaker's bureau for 3M, BSN Medical, Gaymar, KCI, Coloplast, Covidien, J & J (Systagenix), and Mölnlycke; is a member of the speaker's bureau for Galderma; was a recipient of grant/research funding from 3M, BSN Medical, Canadian International Development Agency, Coloplast, Covidien, Government of Ontario, KCI, J & J (Systagenix), Mölnlycke, and the Registered Nurses' Association of Ontario; and is a recipient of grant/research funding from Exciton, J & J (Systagenix), Hollister, and Healthpoint Biotherapeutics. All staff and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. Lippincott CME Institute has identified and resolved all conflicts of interest concerning this educational activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly. This continuing educational activity will expire for physicians on April 30, 2014. Abstract INTRODUCTION METHODS TREAT THE CAUSE 1. Assess the patient's ability to heal. 2. Develop an individualized goal of care. Genetic Engineering Nutrition and Hemoglobin Deep Infection and Inflammation PATIENT-CENTERED CONCERNS 3. Address pain and itch along with potential treatments. 4A. Consider activities of everyday living and restrictions. 4B. Quality of life is affected by local wound care. LOCAL WOUND CARE 5. Document the wounds and their ability to heal. 6. Gently cleanse wounds with low-toxicity solutions. 7. Debridement. 8. Assess and treat superficial critical colonization, deep... 9. Moisture balance—use silicone foams instead of adhesives. 10/11. Evaluate stalled but healable chronic wounds—edge ef... 12. Healthcare system support. SUMMARY REFERENCES Back to Top | Article Outline INTRODUCTION Epidermolysis bullosa (EB) is a rare group of genetic blistering skin diseases with skin fragility leading to bulla formation.1 There is a wide spectrum of severity in EB: the mildest form is localized EB simplex, where blistering predominantly affects the feet and hands, but other forms, notably recessive dystrophic EB (RDEB) and junctional EB, are characterized by more extensive skin and mucosal involvement, systemic complications, disfigurement, and often severely limited life expectancy. It is persons with these more severe forms of EB who have a tendency to develop lifelong chronic wounds and infections. In 2012, a best practice consensus was created examining the issue of wound bed preparation (WBP) that was literally "born on the back" of Alex, a person with RDEB.2 This WBP knowledge can be applied not only to all patients with EB, but also as a model for fragile skin and chronic ulcers (Figure 1). Figure 1 The consensus project united EB experts with wound healers (basic scientists, physicians, and nurse clinicians) with a pioneer in bone marrow transplantation (Table 1). The aim was to facilitate knowledge of the 4 different subtypes of EB so that affected individuals are recognized early and receive appropriate symptomatic treatment, including optimal local wound care to prevent life-threatening infections and failure to thrive. Another objective was to increase awareness of complications such as cardiomyopathy and squamous cell carcinomas (persistent inflammation leads to malignant transformation) that may rarely occur even in childhood. By reading this continuing education article, clinicians will be better able to identify and treat EB and its subtypes. Table 1 Attempts to optimize wound care in EB patients began many years ago. In January 1997, Canada was the first country in the world to approve an artificial skin substitute grown in vitro (Graftskin [Apligraf; Organogenesis, Canton, Massachusetts]: a bovine type 1 collagen with human fibroblasts and an epidermal cell layer). In February 1997, Alex (Figure 1) had 2 pieces of Graftskin placed on the upper part of his extensive back ulceration (covering 50% of his back for 3 years). One week after application, the skin substitutes (with fluid release slits to maintain contact) under the silver and foam dressing were intact. In contrast, the other skin substitute piece without the bacterial balancing silver was destroyed by the local collagenase, partly produced by the Pseudomonas organisms. Subsequent applications of both Vicryl skin substitute populated with human fibroblasts (Dermagraft; Shire Regenerative Medicine, San Diego, California) and Graftskin resulted in complete wound healing of Alex's back. These results were subsequently reproduced on wounds of other EB patients.3,4 Although Alex has since died as a result of infection and cardiomyopathy, his contribution to the better understanding of local wound care has shaped what clinicians know today. The authors have published a model for WBP.5–7 This model includes treating the whole patient, patient-centered concerns, and local wound care. In EB patients, ideal treatment of the cause involves replacing type VII collagen for RDEB patients through bone marrow transplants or other gene-modifying therapies.8 Treating the cause also includes optimizing other cofactors involved in healing, including nutrition (such as supplements and early insertion of feeding tubes) and the correction of anemia. The components of local wound care are as follows: DIM before DIME: debridement, infection/inflammation control, and moisture balance before the edge effect for advanced therapies (eg, skin substitutes for stalled but healable wounds). Trauma and pain associated with local wound care have been improved with local silicone mesh products, soft silicone foam coatings, and silicone tape. Wagner et al9 published a seminal article in 2010 reporting on the first 7 patients with RDEB undergoing immunoablative chemotherapy and allogeneic stem cell transplant. Of the 7 patients, 1 died of cardiomyopathy before transplantation and a second patient died of infection and transplant rejection 183 days after transplantation. All recipients had a reduction in new blister formation between days 30 and 130 after transplantation. Five of the 6 recipients had an increase in type VII collagen expression, but without formation of normal anchoring fibrils. There are 2 key concerns surrounding transplantation procedures. First, the small number of individuals eligible for transplant may develop human leukocyte antigens from the allogeneic cells in the skin transplant, increasing the potential for rejection of a bone marrow transplant. Second, older individuals with RDEB (especially after age 20 years) are very susceptible to aggressive squamous cell carcinomas, and the immunosuppression associated with allogeneic stem cell transplantation may increase this. The authors have currently completed the full circle to apply the principles of wound bed preparation, specifically for people with EB, not only to optimize healing but also to prevent infections and other complications before and after bone marrow transplantation (Figure 2). In addition, the authors are suggesting strategies for persons with EB and their circle of care (parents and healthcare providers) in resource-poor areas where links to EB experts will help improve diagnosis and treatment. Figure 2 Epidermolysis bullosa also represents a model for fragile skin found in older adults, Skin Changes at Life's End,10 and other patients suffering from chronic disease or immunosuppression. Therefore, the principles discussed in this article can be applied to other patient populations with skin fragility. Back to Top | Article Outline METHODS The process of consensus building with a full discussion of the dermatological and general medical components of the care of individuals with EB has been published elsewhere.2 Briefly, the recommendations were generated by a diverse panel of 11 experts and reviewed by 15 external reviewers (Tables 1 and 2). Inclusion of recommendations was contingent on 80% agreement from responders. Table 2 This article summarizes the EB recommendations with a special emphasis on the wound healing component as outlined with the WBP paradigm and utilizes EB as a model for fragile skin. Back to Top | Article Outline TREAT THE CAUSE 1. Assess the patient's ability to heal. Back to Top | Article Outline 2. Develop an individualized goal of care. Epidermolysis bullosa is caused by mutations in structural proteins with resultant fragile skin. There are currently 4 main subtypes described, based on the specific genetic defect and the level at which blisters form in the skin in response to trauma (Figure 3).1,11 Figure 3 Epidermolysis Bullosa Simplex: The most common type of EB simplex is localized EB simplex with skin cleavage within the basal layer of the epidermis. The blisters are usually on the palms and soles, aggravated by heat and friction. The inheritance is autosomal dominant with mild disease. Mutations are present in keratins 5 or 14. A less common but also autosomal dominant type, Dowling-Meara, features clustered distal blisters with a string of pearl-like arrangement. Although painful keratoderma is noted with time, patients tend to be less severe with increasing age. Junctional EB: Skin and mucosal cleavage occurs at the lamina lucida level of the basement membrane zone, including periorificial areas of skin, ocular, tracheolaryngeal, gastrointestinal, genitourinary, and renal systems. The mode of inheritance is usually autosomal recessive, with mutations in the genes encoding collagen XVII, α6β4 integrin, or laminin 332. The Herlitz form is the most severe (exuberant granulation in the perioral area, around the nails, and denuded diaper area), with death in most cases in the first 1 to 2 years of life. The non-Herlitz form is often severe in infancy, but life expectancy is considerably longer. Dystrophic EB: This type of EB involves cleavage beneath the lamina densa, within the dermis at the level of the anchoring fibrils due to mutations in the type VII collagen gene.l The autosomal dominant form is the second most common EB type, and patients present with blisters in areas prone to bumps or knocks such as the toes, knees, fingers, and elbows. The autosomal recessive form is usually more debilitating, with blisters from birth and pseudosyndactyly, where toes and fingers become fused. This form is associated with lifelong chronic wounds and with the development of aggressive squamous cell carcinomas in the 30s to 40s. If they reach their mid-50s, 90% of individuals will have had a squamous cell carcinoma. Kindler Syndrome: This rare form of EB may result in cleavage at any of the 3 levels outlined above. Blisters in early childhood are gradually replaced by scarring, keratoderma (thickened palms and soles), poikiloderma (hypopigmentation and hyperpigmentation, telangiectasia, and atrophy), and photosensitivity. It is caused by mutations in the gene encoding kindlin 1, which is involved in basal layer keratinocyte adhesion at focal contacts. Back to Top | Article Outline Genetic Engineering Until recently, care of patients with EB has consisted of trying to minimize trauma-induced blistering of the skin and supportive care of resulting wounds. However, there are some new and exciting therapies being proposed to target the cause of the skin fragility in these patients, including replacement of the abnormal protein (eg, collagen VII in RDEB) and bone marrow transplantation. Recent studies have suggested that delivery of allogeneic fibroblasts to the skin of patients with RDEB may be beneficial in improving skin adhesion and increasing type VII collagen deposition at the dermal-epidermal junction.12 There are promising data from patients with RDEB treated with immunomyeloablative chemotherapy and allogeneic stem cell transplantation, resulting in improved wound healing, decreased blister formation, and increased collagen VII deposition at the dermal-epidermal junction. Although encouraging, further study is needed to determine long-term safety and efficacy of this modality.9 Until then, treatment goals are aimed at optimizing wound healing and minimizing disability from blistering. Back to Top | Article Outline Nutrition and Hemoglobin There are many different ways in which nutrition may be compromised in patients with EB; both poor dietary intake and increased metabolic demands can impair wound healing.13 Adequate protein is a prerequisite to good wound healing through its integral role in the production of granulation tissue, and albumin levels less than 2.0 to 3.0 g/dL can have a negative impact (reference range, 3.0–5.4 g/dL).14,15 To optimize nutrition, a dietitian should be consulted to calculate caloric intake and ensure that the diet includes adequate amounts of protein, zinc, and iron in forms that are palatable for patients, especially those with fragile mucosal barriers. Feeding tubes are often required in children with RDEB and other severe types of EB to improve growth centiles or a very low body mass index. Low hemoglobin can affect tissue oxygenation and will also inhibit healing in people with EB.16 There are several reasons for increased blood loss and decreased production of red blood cells, including: increased blood loss through blisters and chronic wounds on the skin and in the gastrointestinal tract chronic inflammation leading to decreased production of red blood cells iron deficiency and increased iron utilization deficiencies of other vitamins and minerals including vitamin B12 and folate. Although there is evidence for targeting hemoglobin levels to levels greater than 100 g/dL,16 for many individuals with severe EB and chronic wounds, a hemoglobin of 80 g/dL is a more realistic recommendation. Attempts to maintain the hemoglobin at higher levels lead to the potential for iron overload from intravenous iron or blood transfusions. Back to Top | Article Outline Deep Infection and Inflammation Chronic wounds with large open areas are often stuck in the inflammatory stage of the healing process. Proinflammatory metalloproteases and elastases can be derived from both the host and critically colonizing bacteria. Antimicrobials have a known spectrum of antibacterial action, but some antimicrobials also have an anti-inflammatory action that can promote healing both by decreasing bacterial numbers in the wound but also by decreasing inflammation. In young infants, erythromycin is a reasonable agent for anti-inflammatory and antimicrobial effects, with trimethoprim (TMP) an appropriate alternative after 6 months of age. Tetracyclines should be reserved for older children after the emergence of permanent teeth. Both infection and inflammation can impair wound healing. All wounds are colonized with bacteria and infection results when the bacterial load and virulence overcome the ability of the patient's immune system to resist invasion. Once infection occurs, treatment takes 2 to 4 weeks.7 Inflammation is present in many wounds, but can be prolonged and stall healing when degradation of extracellular matrix and growth factors occurs more rapidly than the collagen matrix synthesis.17 Observational data have suggested that patients with more severe forms of EB treated with long-term, low-dose, anti-inflammatory antibacterial treatment, such as erythromycin or TMP, have reduced wound severity and develop fewer new blisters.18 In a small cohort of children with EB, TMP was associated with a trend toward a greater reduction in the total wound surface area compared with placebo.18 Back to Top | Article Outline PATIENT-CENTERED CONCERNS 3. Address pain and itch along with potential treatments. Pain and itch are very common and debilitating symptoms in EB with significant effects on quality of life.19 Various recommendations have been made to help prevent pain. Skin protection to avoid trauma includes use of silicone adhesives or foam dressings, modified sleeping and seating surfaces, and good footwear. Releasing fluid from blisters, while leaving the roof intact, can prevent blister expansion.6 Finally, the use of hand cleansers and clean techniques when changing dressings can avoid potential translocation of bacteria into areas of compromised skin and increased risk of superficial critical colonization or deep or secondary painful infection. To help treat pain, it is important to distinguish nociceptive from neuropathic pain. Nociceptive pain is characteristically described as gnawing, aching, tender, or throbbing, provoked by stimulus, and can be treated with a stepwise approach proposed in the World Health Organization's pain ladder.20,21 Acetaminophen is used first, with subsequent addition of nonsteroidal anti-inflammatory medications (ibuprofen or naproxen) and then narcotics (morphine, hydromorphone) as needed for optimal pain control. Neuropathic pain is burning, stinging, shooting, or stabbing and requires modalities such as tricyclic antidepressants (amitriptyline, or more selective nortriptyline or desipramine) or anticonvulsants (gabapentin, pregabalin). It is important to obtain a good history of the presence and timing of itch, in order to tailor therapies to target or prevent triggers. For patients who experience nighttime itch, a sedating medication such as diphenhydramine may be beneficial. Uncommonly, diphenhydramine may produce paradoxical excitement instead of sedation or leave patients groggy in the morning. In these cases, hydroxyzine or doxepin may be helpful alternatives. Hydroxyzine syrup allows for very small doses to be administered, and the drowsiness is often less severe by morning, but the effect in the skin may last for up to 72 hours. For daytime itch, nonsedating antihistamines, such as cetirizine or loratadine, can be used; however, a small subset of patients may experience drowsiness with these products. Refrigeration of topical products used on the skin can also produce a cooling sensation and minimize itch. Back to Top | Article Outline 4A. Consider activities of everyday living and restrictions. Epidermolysis bullosa patients carry a large disease burden with impacts on all aspects of daily living. It is helpful to involve occupational and physiotherapists to maximize independence in activities of daily living, as well as leisure activities. It is also important to screen for concurrent anxiety or depression with appropriate referrals where indicated and provide psychosocial support with information about support and patient advocacy groups. Back to Top | Article Outline 4B. Quality of life is affected by local wound care. The frequency of dressing changes and time involved depends on the extent of the wounds and the dressings used. Although many foam dressings can be left in place for up to 7 days, most patients with severe EB require dressing changes every day to every 1 to 3 days. The amount of exudate from the wound along with odor or discomfort will often determine the frequency of dressing changes. If materials stick, dressing changes may be facilitated by bathtub bathing and soaking. Baths are preferred over showers that can cause extension of the blisters due to pressure from the water stream. The dressing changes take time, and the dressings themselves can be hugely expensive. Community nurses are sometimes required to help with dressing changes, which adds a layer of scheduling inconveniences and system costs above those already mentioned. The dressing changes are often very painful, and if so, it is important to recommend that the patient take an analgesic approximately 30 minutes before the anticipated change. The need for dressing changes and limitations on mobility makes schooling and employment challenging for many of the more severe types of EB patients. Back to Top | Article Outline LOCAL WOUND CARE 5. Document the wounds and their ability to heal. Documentation of wounds is best achieved by location—a body diagram with the wound location and size is often useful. It is also important to see the entire skin of a person with EB at least every 6 months. A rotational system should be worked out with the patient and his/her circle of care, so that at each visit the most severe wound is examined along with the needed other areas of the body to complete the every-6-months skin rotation. Any wound that appears atypical with stalled healing should be biopsied. This is particularly important for people with RDEB, where aggressive squamous cell carcinomas are very common and can develop at a very young age. The current recommendation is screening surveillance every 6 months from the age of 10 years in this group of patients. The risk of developing these lesions increases to 90% of individuals who survive over the age of 50 years.22 One framework that can be used for wound assessment is the modified MEASURE paradigm (measure size, exudate [amount and characteristics], appearance [base or granulation tissue], suffering [pain], undermining [depth measured in centimeters], re-evaluate, and edge).23 This documentation provides a good assessment of the extent of the wound in its current state, as well as a good tool for monitoring the healing process. A modified model tailored to patients with EB is outlined below in more detail, with the deletion of undermining. Size: This is measured with the longest length and the widest width at right angles to the longest length. Exudate: Exudate is derived from the dermis or deeper structures and consists of varying amounts of serum, blood, or pus. The most predominant component should be listed first and then the subsequent component(s). For example, serosanguineous exudate has more serum than blood, or all 3 components may be present such as sero–pustular-sanguineous. The amount of exudate is then quantitated as none, scant, mild, moderate, or heavy. For example, when the dressing is removed, if there is less than 25% of the surface soiled, the exudate could be categorized as scant; with 25% to 50%, it would be a mild exudate; 50% to 75%, moderate exudate; and more than 75% or wound exudate dressing strikethrough (leakage) would indicate a heavy exudate. Appearance: The wound base and the margin should be assessed. The base can have black, yellow, or red-pink tissue. Black tissue usually indicates necrosis or tissue death. Yellow can be fibrin in the wound base that may be healthy, and the lattice framework for pink buds of healthy granulation to appear. This needs to be distinguished from loose yellow slough that represents dead surface cells. Healthy granulation tissue is firm and pink. It needs to fill the wound base to the level of the wound edge for epithelium to migrate across the surface as quickly as possible. Unhealthy granulation tissue has a bright red color, is friable, and bleeds easily. When a dressing is removed, blood may be obvious on the inner aspects of the dressing, and punctate bleeding points are seen on the wound surface. This type of granulation is often associated with critical colonization of the wound surface and may respond to topical antimicrobial agents. The wound base can be characterized as having 50% healthy pink granulation and 30% unhealthy bright red friable granulation, with 20% yellow slough. Wound edges may be healthy or unhealthy. A healthy wound edge often has a tapered appearance like a sandy beach and water interface. This is often surrounded by a rim of new epithelium that is often purple in color. A stalled or nonhealing chronic wound often has a cliff-like edge due to stalled epithelial migration. Unhealthy wound margins may be red, warm, and edematous with infection spreading into the wound margin or macerated if there is excess exudate in the wound base that is not managed by the dressing. Suffering (Pain): Pain needs to be documented and is best measured with an 11-point numerical rating scale. The patient is given direction that 0 is no pain and 10 is like slamming your finger in a car door, with 5 representing a bee sting, where is your pain now? The pain can then be characterized as nociceptive or neuropathic and treated by the criteria in the section above on patient-centered concerns.20 Young infants may relate best to the pictures in the Faces Pain Scale. Most individuals can live with a pain level of 2 to 3 out of 10. Pain levels of 4 or higher should be treated. Itch can be as troublesome as pain and needs treatment, despite the less than optimal results from many of these patients with traditional sedating antihistamines. Reassessment: Wounds that are not 30% smaller by week 2 to 4 are unlikely to heal by week 12.24 Because many patients with EB, especially severe cases, have multiple medical problems and suboptimal hemoglobin and serum albumin levels, maintenance or nonhealable wounds are common. Healing may not always be the primary goal; however, it is desirable. Controlling pain and preventing infection are often the most important elements. Edge Effect: This is where patients who have had optimal treatment of the cause and aggravating factors (where possible), along with patient-centered concerns and local wound care, may benefit from advanced therapies as outlined in Figure 2. Back to Top | Article Outline 6. Gently cleanse wounds with low-toxicity solutions. Once the old dressing has been removed, the area should be gently cleaned with solutions with low or no toxicity. Options include saline solution, water, or solutions with low concentrations of acetic acid (white vinegar—5% diluted 1 in 5 or 1 in 10), benzalkonium chloride, and/or chlorhexidine. Some patients may not tolerate the vinegar because of burning or stinging, and the cleansing agent should be rotated in these cases. The gauze can be saturated with the solution and applied as a soak to hydrate the wound surface with the net movement of liquid from the gauze to the wound surface. Alternately the same material can be squeezed or wrung out leaving damp gauze to apply to the wound, resulting in a compress that acts as an astringent (coagulates protein). The net movement from a compress is from the wound surface to the gauze and results in removal of surface debris. With both methods, the cloth should be changed every 30 to 60 seconds to complete the cleansing process. Irrigation is too harsh for the fragile skin associated with EB. Dilute acetic acid will lower the pH of the wound surface, and this is often helpful to remove Pseudomonas or other gram-negative organisms from the wound surface that thrive in an alkaline environment. Pseudomonas has a lower virulence than most gram-positive organisms (eg, Staphylococcus aureus or Streptococcus) and can often be treated topically rather than with systemic antibiotics, and it is best to consider 2 topical antimicrobials (such as acetic acid with silver or iodine preparations). Back to Top | Article Outline 7. Debridement. The inherent skin fragility of patients with EB requires that extra care be taken in the changing of dressings and local wound care in order to prevent further skin damage from mechanical friction or trauma. Bathing or soaking areas before removing old dressings can minimize pain and avoid tearing off a superficial blister roof. Bath water can be made antimicrobial by adding dilute acetic solution (5% white vinegar diluted to 0.25%–1.0%), or bleach (5–10 mL in 5 L of water) may decrease the bacterial carriage.25 It is important to rinse off either of these solutions with clean water after bathing. If intact blisters are present, they should be punctured with a sterile needle and gentle pressure applied to remove the contents. The roof should be left to act as a natural biologic dressing. If crusts (scabs) have formed over the wound, they should be soaked and carefully lifted off as the presence of the eschar can impair healing and create a proinflammatory stimulus. Back to Top | Article Outline 8. Assess and treat superficial critical colonization, deep and surrounding infection, or inflammation. The presence of infection or inflammation should be clinically assessed and documented. Helpful tools include the mnemonics NERDS (nonhealing; increased exudate; red, friable tissue; debris, dead slough; smell) and STONEES (increased size; temperature [3° F warmer than contralateral skin]; os, exposed/probing to bone; new areas of breakdown; erythema/edema of surrounding skin; increased exudate and smell).26 If there are 3 or more NERDS criteria, a topical antimicrobial agent may be beneficial including topical dressings with silver, iodine, polyhexamethylene biguanide, honey, or topical surfactants. Care should be taken using silver dressings or topical products in children as systemic absorption occurs. Some of these dressings may sting and burn on application, and often it is important to respect patient preference with careful monitoring of the clinical results. More detail on these choices can be found in Wound Bed Preparation 20117 or the complete report on the consensus document.2 For deep infections, treatment will be based on empirical choices that should have broad-spectrum coverage, and then more specific anibiotics can be ordered based on the culture and sensitivity results. Back to Top | Article Outline 9. Moisture balance—use silicone foams instead of adhesives. The choice of dressing depends on the wound characteristics, but should be selected with a goal of optimal moisture balance. In EB patients, silicone foam dressings work well as they allow large amounts of fluid to be absorbed while providing protective padding and will not adhere strongly to the skin when removed preventing pain and trauma on removal.2 Other nonadherent moisture balance dressings will also be useful with calcium alginates for areas of bleeding or hydrogels/hydrofibers for gentle moisture balance where fluid donation or fluid lock is required. Some highly exudative wounds require fluid lock technology with superabsorbent dressings with diaper-like technology. Back to Top | Article Outline 10/11. Evaluate stalled but healable chronic wounds—edge effect: when to use advanced therapies. Healable wounds should be 30% smaller by week 4 to heal by week 12. If a wound has not healed at the expected rate, it may be stalled. Advanced therapies can be considered in these circumstances and include advanced wound care matrices, a group of cellular (living cells) or acellular (biologically inert) products derived from biological (animal, human, or plant), synthetic, or composite (combined) sources.27 Unfortunately, the evidence to date for these therapies has resulted from studies of other chronic wounds and has not been evaluated in wounds on patients with EB.7 Apligraf and Dermagraft are living skin substitutes, both supplying a dermal layer with fibroblasts and collagen, which produce matrix proteins. Apligraf also has an epidermal layer produced from multiplying keratinocytes forming a replicated architecture of human epidermis. Studies of the use of Apligraf and Dermagraft in EB have shown promising effects,4 but further evaluation needs to be completed to demonstrate cost-effectiveness in patients with EB to facilitate healthcare system coverage. Back to Top | Article Outline 12. Healthcare system support. The treatment of EB is complex and requires a host of interprofessional team members for optimal care (Figure 4). Figure 4 Over the past decade, EB specialized clinics have opened in 16 countries. Other resources exist in DebRA programs worldwide (http://www.debra.org/international) or through http://www.internationalebforum.org/index.php?id=16. Each new case requires a diagnosis and typing or subtyping assoon as possible. Healthcare systems need to build support networks such as the one established in the United Kingdom that provides ongoing support from knowledgeable practitioners. Families need to regroup, and healthcare providers need to be flexible to build trust and improve patient outcomes. Back to Top | Article Outline SUMMARY Epidermolysis bullosa is a highly complex, multisystem disease, with severe EB types having devastating effects on the quality of life and life span of affected patients and their families. Wound care requires an interprofessional coordinated approach that addresses the patient as a whole. The authors have brought together experts in the field of EB, the science of wound care, and clinical wound care practice to provide the best available approaches for optimal wound care to people with EB. Until a definitive cure becomes available, these practice goals are to minimize suffering, improve wound healing, and prepare patients for potential corrective procedures, thereby improving the lives of affected individuals. PRACTICE PEARLS Back to Top | Article Outline REFERENCES 1. Fine JD, Eady RA, Bauer EA, et al.. The classification of inherited epidermolysis bullosa (EB): report of the Third International Consensus Meeting on Diagnosis and Classification of EB. J Am Acad Dermatol 2008; 58: 931–50. Cited Here... | View Full Text | PubMed | CrossRef 2. Pope E, Lara-Corrales I, Mellerio J, et al.. A consensus approach to wound care in epidermolysis bullosa. J Am Acad Dermatol 2012; 67: 904–17. Cited Here... | View Full Text | PubMed | CrossRef 3. Fivenson DP, Scherschun L, Choucair M, et al.. Graftskin therapy in epidermolysis bullosa. J Am Acad Dermatol 2003; 48: 886–92. Cited Here... | View Full Text | PubMed | CrossRef 4. Sibbald RG, Zuker R, Coutts P, Coelho S, Williamson D, Queen D. Using a dermal skin substitute in the treatment of chronic wounds secondary to recessive dystrophic epidermolysis bullosa: a case series. Ostomy Wound Manage 2005; 51 (11): 22–46. Cited Here... | PubMed 5. Sibbald RG, Orsted H, Schultz GS, Coutts P, Keast D; International Wound Bed Preparation Advisory Board; Canadian Chronic Wound Advisory Board. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Manage 2003; 49 (11): 23–51. Cited Here... 6. Kirshen C, Woo K, Ayello EA, Sibbald RG. Debridement: a vital component of wound bed preparation. Adv Skin Wound Care 2006; 19: 506–17. Cited Here... | View Full Text | PubMed | CrossRef 7. Sibbald RG, Goodman L, Woo KY, et al.. Special considerations in wound bed preparation 2011: an update©. Adv Skin Wound Care 2011; 24: 415–36. Cited Here... | View Full Text | PubMed | CrossRef 8. Kiuru M, Itoh M, Cairo MS, Christiano AM. Bone marrow stem cell therapy for recessive dystrophic epidermolysis bullosa. Dermatol Clin 2010; 28: 371–82. Cited Here... | PubMed | CrossRef 9. Wagner JE, Ishida-Yamamoto A, McGrath JA, et al.. Bone marrow transplantation for recessive dystrophic epidermolysis bullosa. N Engl J Med 2010; 363: 629–39. Cited Here... | View Full Text | PubMed | CrossRef 10. Sibbald RG, Krasner DL, Lutz J. SCALE: Skin Changes at Life's End: final consensus statement: October 1, 2009. Adv Skin Wound Care 2010; 23: 225–36. Cited Here... | View Full Text | PubMed | CrossRef 11. Intong LR, Murrell DF. Inherited epidermolysis bullosa: new diagnostic criteria and classification. Clin Dermatol 2012; 30: 70–7. Cited Here... | PubMed | CrossRef 12. Wong T, Gammon L, Liu L, et al.. Potential of fibroblast cell therapy for recessive dystrophic epidermolysis bullosa. J Invest Dermatol 2008; 128: 2179–89. Cited Here... | PubMed | CrossRef 13. Mellerio JE, Weiner M, Denyer JE, et al.. Medical management of epidermolysis bullosa: proceedings of the IInd International Symposium on Epidermolysis Bullosa, Santiago, Chile, 2005. Int J Dermatol 2007; 46: 795–800. Cited Here... | View Full Text | PubMed | CrossRef 14. Bolitho C, Xaymardan M, Lynch GW, Zoellner H. Vascularity during wound maturation correlates with fragmentation of serum albumin but not ceruloplasmin, transferrin, or haptoglobin. Wound Repair Regen 2010; 18: 211–22. Cited Here... | View Full Text | PubMed | CrossRef 15. Posthauer ME. The role of nutrition in wound care. Adv Skin Wound Care 2012; 25: 62–3. Cited Here... | View Full Text | PubMed | CrossRef 16. Keast DH, Fraser C. Treatment of chronic skin ulcers in individuals with anemia of chronic disease using recombinant human erythropoietin (EPO): a review of four cases. Ostomy Wound Manage 2004; 50 (10): 64–70. Cited Here... | PubMed 17. Trengove NJ, Stacey MC, MacAuley S, et al.. Analysis of the acute and chronic wound environments: the role of proteases and their inhibitors. Wound Repair Regen 1999; 7: 442–52. Cited Here... | PubMed | CrossRef 18. Lara-Corrales I, Parkin PC, Stephens D, et al.. The efficacy of trimethoprim in wound healing of patients with epidermolysis bullosa: a feasibility trial. J Am Acad Dermatol 2012; 66: 264–70. Cited Here... | View Full Text | PubMed | CrossRef 19. van Scheppingen C, Lettinga AT, Duipmans JC, Maathuis CG, Jonkman MF. Main problems experienced by children with epidermolysis bullosa: a qualitative study with semi-structured interviews. Acta Derm Venereol 2008; 88: 143–50. Cited Here... | PubMed | CrossRef 20. Woo K, Sibbald G, Fogh K, et al.. Assessment and management of persistent (chronic) and total wound pain. Int Wound J 2008; 5: 205–15. Cited Here... | View Full Text | PubMed | CrossRef 21. Sarzi-Puttini P, Vellucci R, Zuccaro SM, Cherubino P, Labianca R, Fornasari D. The appropriate treatment of chronic pain. Clinical Drug Investig 2012; 32 (Suppl 1): 21–33. Cited Here... 22. Fine JD, Johnson LB, Weiner M, Li KP, Suchindran C. Epidermolysis bullosa and the risk of life-threatening cancers: the National EB Registry experience, 1986-2006. J Am Acad Dermatol 2009; 60: 203–11. Cited Here... | View Full Text | PubMed | CrossRef 23. Keast DH, Bowering CK, Evans AW, Mackean GL, Burrows C, D'Souza L. MEASURE: a proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen 2004; 12 (3 Suppl): S1–17. Cited Here... 24. Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. The accuracy of venous leg ulcer prognostic models in a wound care system. Wound Repair Regen 2004; 12: 163–8. Cited Here... | View Full Text | PubMed | CrossRef 25. Mellerio JE. Infection and colonization in epidermolysis bullosa. Dermatol Clin 2010; 28: 267–9. Cited Here... | PubMed | CrossRef 26. Woo KY, Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage 2009; 55 (8): 40–8. Cited Here... | PubMed 27. Hankin CS, Knispel J, Lopes M, Bronstone A, Maus E. Clinical and cost efficacy of advanced wound care matrices for venous ulcers. J Manage Care Pharm 2012; 18: 375–84. Cited Here... | PubMed | CrossRef Figure Figure Keywords:epidermolysis bullosa (EB); skin diseases; EB simplex; junctional EB; dystrophic EB; Kindler syndrome © 2013 Lippincott Williams & Wilkins, Inc.


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The Great IT Pro Trade
Sara Peters, Editor in Chief | 2/21/2014 | 38 comments
If youre a hiring manager, it sounds pretty great, doesnt it? Well, if you managed a the sports team, this would be the normal order of business. Yesterday afternoon, the basketball community was on tenterhooks waiting to find out which NBA players would be traded before the season trade deadline at 3:00 p.m. Eastern Time. As of that moment, no more trades can be made for the rest of the basketball season.
As I listened to learn who would be changing teams that day, I got to wondering if such a thing might work in IT. Surely all IT personnel would like to be on a team that wanted them and needed them. And surely anyone would prefer to have that handed to them instead of grinding through job applications. And wouldn't it be nice to go through that entire process out in the open, with your company's approval?
In theory it doesn't sound so bad, but in practice, sports trades can be stressful, messy, and often painful. Players rarely have any say over whether or not they're going to be traded, and where it is they're going to be traded to. Sometimes they don't even know they've been put on the market until they hear the rumors in the media. Then they have to keep performing at their best, trying to ignore all those rumors fluttering around them. Sometimes players don't know that they were put on the market until the deal goes through. Some players hear about it on the news before they get the call from their management.
Yesterday, one player was in the middle of warming up before a game when he was told to change, hop on a plane, go to a new city, and get a new uniform, and tonight he'll be playing for an entirely different team, hoping his family will be able to relocate to his new home soon.
These aren't rare situations. They're quite common, and it's really rather horrid. However, if we could make the trade system more humane, and make the people being traded more a part of the process, could we make something like this work in IT? There would be a few challenges.
First, sports business people have half the competitive season to watch and assess the entire league's talent on TV. IT people aren't always on display in this way, so first we'd need a way to properly advertise our team's best work. Developers would have a rather easy time showing their labors in their portfolio, but other IT jobs -- database administrators, help desk associates, network architects -- would find it a bit harder to show off.
The sports world is also very keen on statistics. So we'd need plenty of standardized metrics. Perhaps in lieu of the Wins-Losses column, we'd use Money Made-Lost. Instead of points scored we'd count sales made (with online shops and new PoS solutions). Instead of assists we'd measure help desk tickets cleared. Instead of rating defense, we'd rate compliance. We could measure things like time to deployment, or user satisfaction rating, or energy efficiency, and the like.
It would certainly make the task of creating meaningful metrics more fun. Heck, maybe people would start a Fantasy IT League.
Maybe I'm crazy. I often am. But I still think that there is merit in the idea of putting together the very best team you can by collaborating with other companies. What do you think? What kind of things would you want to know about your competitors' talent before you accepted a trade? Would you ever allow yourself to be traded? Let us know in the comments below.
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Link to this page: https://www.socialistparty.org.uk/issue/685/12771
From The Socialist newspaper, 14 September 2011
Hundreds march against Dale Farm evictions
Dave Murray, Basildon Socialist Party
"In 100 years we've never had so much support," said Grattan Puxon of the Gypsy Council, addressing the hundreds of people who marched in opposition to the evictions at Dale Farm on Saturday 10 September.
The defiant but festive tone of the march was set by the Travellers who led the procession with their banner - "No ethnic cleansing" - and taken up by their supporters.
There was a large and visible police presence, backed up by a reserve force which included mounted and armed officers.
The local newspaper had billed the demo as a potential flashpoint for some unspecified "trouble". Thus, a number of shops in the town centre of Wickford, through which the demo marched, were closed.
Undismayed, scores of local people gathered to watch the march pass, enduring no more than sunshine, samba and appeals for solidarity.
At a very uncertain time for the residents of Dale Farm, the march provided a welcome boost in morale.
For more info: www.dalefarm.wordpress.com
Dale Farm Solidarity has asked for supporters to be at Dale Farm on 19 September, which is believed to be the eviction date.
Why not click here to join the Socialist Party, or click here to donate to the Socialist Party.
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Austerity policies strangle growth
Socialist Party youth and students
Pampered politicians plan education massacre... STOP THEM!
Low pay and the housing crisis
Youth must join pensions struggle
EMA cuts: doors close on our future
Cuts hit young people hard in Hastings
Stop attacks on pensions
NHS pensions - Pay more, work longer and get less!
Socialist Party workplace news
No to pay cuts in Carmarthenshire
International socialist news and analysis
How can the national rights of Palestinians be achieved?
Socialist Party news and analysis
NSSN calls on TUC to open the floodgates of mass action
Nationalise the banking system!
Childcare costs push parents into hardship
Socialist Party review
Socialist Party reports and campaigns
Bristol: Labour's short-lived valour
Hundreds march against Dale Farm evictions
May Day protest case goes to Strasbourg
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I don't know a better name for this dish. Chicken wrapped with thinly sliced ham, cheese, and tomatoes. Baked into moist-goodness. Choose to make as many as you want.
Preheat oven 375
You will need:
- Chicken breast cutlets pounded thin****Buy the already pounded thin chicken breasts (I think Perdue makes some). Otherwise pound thin as many boneless/skinless chicken breasts as you want to make.
- thinly sliced ham
- thinly sliced cheddar or provolone cheese
- finely chopped tomato
- fresh chopped rosemary
- small dish of melted butter or margarine
- Italian bread crumbs
Once pounded thin, place a piece of ham (if breast is big, can overlap two pieces), a piece (or two) of cheese, sprinkle on some finely chopped tomato, sprinkle with rosemary. Roll up and secure with toothpick if need to. Dip in melted butter and roll in bread crumbs. Bake 40-45 min, depending on thickness.
Friday, April 9
Yummy Chicken
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"…and cleanse me from my sin…Cleanse me with hyssop, and I will be clean; wash me, and I will be whiter than snow" (Psalm 51:2b, 7).
There are always consequences of our sins – people we love get hurt, we damage ourselves physically, someone might be turned off to hearing about Christ because of a sin we commit as a Christian, etc. Yet, "Because of the Lord's great love we are not consumed, for his compassions never fail. They are new every morning; great is your faithfulness" (Lamentations 3:22-23). "…let us draw near to God with a sincere heart in full assurance of faith, having our hearts sprinkled to cleanse us from a guilty conscience…" (Hebrews 10:22). Doesn't it feel wonderful to be clean? Especially after you've been dirty! There is nothing like a nice, hot shower and clean clothes! That's such a good picture of what God does with our sin! He washes us clean, and gives us clean clothing to put on – clothing that reflects His glory and is a testimony to others. "If we confess our sins, he is faithful and just and will forgive us our sins and purify us from all unrighteousness" (1 John 1:9).
How grateful I am Lord, that you not only forgive, but bring your purity into my life. Thank you for the cleansing that is mine through the blood of Jesus Christ.
–Adapted from Pray Like the King (Lessons from the Prayers of Israel's Kings) by David and Kim Butts. This book is available at prayershop.org. Use the code CONPSP3 at checkout to receive an additional 10% discount.
Prayer PointsPraise God because he is the encourager and comforter of his people. Give thanks that God loved you and by his grace gave you eternal encouragement and good hope (2 Thess. 2:16). Ask forgiveness for all those times when fear and anxiety replace the courage that God gives. Commit yourself to seeking God's encouragement to face every obstacle in your life. Ask God to encourage your heart and strengthen you in every good deed and word (2:17).
Pray for special encouragement for teachers as they educate. Pray that parents will be supportive of teachers who seek what is best for students.
–Prayer Points taken from Patterns for Prayer by Alvin VanderGriend.
Connection (Devotions for Everyday Life) © 2019 is published daily by Harvest Prayer Ministries. Subscribe here.


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Crime - Sacto 911
Pedestrian killed by truck in early morning accident
What to do if you've been in a car accident
A semi truck struck and killed a pedestrian early Tuesday in south Sacramento, according to the Sacramento Police Department.
Officer Eddie Macauley, Sacramento police spokesman, said police received a call about 4:28 a.m. from a truck driver saying he had just struck a pedestrian on Florin Perkins Road.
The truck was turning northbound on Florin Perkins from Fruitridge Road when the driver thought he hit something and saw a shopping cart, Macauley said. When the driver checked, he saw a man had been struck.
The name of the man who died had not been released.
SPD units onscene of fatal veh v. ped collision. Florin Perkins Rd from 23rd Ave to Fruitridge Rd closed to all traffic. Please avoid area pic.twitter.com/AjVCuiKFaN— Sacramento Police (@SacPolice) August 8, 2017
Macauley said the truck driver remained at the scene and cooperated with police in their investigation. He said the driver did not appear to be impaired by drugs or alcohol.
Florin Perkins Road was closed to traffic between Fruitridge Road and 23rd Avenue until about 9 a.m. to allow for the investigation..
Jacob Sweet: 916-321-1052, @_jacobsweet


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Thunder Turnaround Sends Spurs Packing
By Randy Renner, Senior Writer
For a while on Thursday night Andre Roberson became what the Thunder have always wanted him to be.
A "3 & D" guy. Someone who could knock down some threes while locking down the other team's best offensive player.
About halfway through the third quarter of OKC's 113-99 win over San Antonio that closed out the Spurs and sent the Thunder on to the Western Conference Finals, Roberson had 11 points on 4-for-5 shooting overall and 3-for-3 on threes. Kawhi Leonard had 10 points on 4-for-13 shooting and no threes.
"I thought Andre played very, very well," said Thunder head coach Billy Donovan. "He got some open threes and shot the ball very well."
"He did a great job," acknowledged Spurs coach Gregg Popovich. "He actually made three 3s which makes his defense which makes his defense even more special."
Roberson has been enough of a pest for Leonard that the Spurs best all-around player was not able to dominate on either end of the floor. Roberson's defense is a given but he'd missed all seven of his 3-point attempts in the first five games of the series. Knocking down his first three 3s last night helped keep the Spurs on their heels.
And on their heels is where the Spurs spent most of the series. After blowing out the Thunder in Game 1 and looking like they couldn't possibly lose a game much less the series things had been trending the Thunder's way.
"I give our guys a lot of credit for how they paid attention and locked in and tried to get better and improve" after that first game Donovan told reporters.
Russell Westbrook, who had just 14 points on 5-for-19 shooting in that opening game, said everyone just put the loss behind them and started over.
"We came out after that and had a different mindset," he said. "We knew what we had to do to beat (the Spurs) and I'm just proud of our guys, everyone stepped up."
Serge Ibaka stepped up and right smack into the path of Spurs future Hall of Famer Tim Duncan late in last night's fourth quarter and made perhaps the play of the game.
Duncan was turning back the clock in the second half and the Spurs were gobbling up what had been a 28 point Thunder lead. OKC led by just 11 with still 3:12 to play. Duncan was rolling down the lane and going up for a dunk that would have sliced that once fat lead down to skinny single digits.
Except there was Ibaka.
He'd been kind of pushed out of the spotlight by the increased playing time and production of Steven Adams and Enes Kanter, who'd finished the last games on the court together while Ibaka watched from the bench.
But in that moment last night, with the game teetering, Ibaka stoned Duncan's dunk attempt, swatting it away for his third block of the evening. The move set the Chesapeake Energy Arena crowd to roaring again and took the air out of the Spurs sails.
"We always give credit to our opponents, and obviously, OKC turned it up there and turned our execution into forced bad shots, and then we kind of trickled down from there and it snowballed," Duncan said. "We put ourselves in the hole. We actually played somewhat solid for the second half but it was too little, too late."
And when it comes to stepping up and doing whatever it takes what can you say about Adams' effort?
Kid Kiwi was throwing up in the Thunder training room before the game. He suffers from migraine attacks once in a while and one was coming on hard and fast about an hour before tipoff.
Teammates were horrified, Kanter wasn't even allowed back in the training room to check on his fellow Stache Brother so ugly was the scene.
But Adams wasn't gonna let a headache stop him from playing in the most important game of his short career even though he said it felt like "an old mate with a sledgehammer just pounding at the back of my eye."
Thunder trainers gave him an IV to help restore the fluids he was losing and out onto the court he went just before tipoff.
He hadn't even warmed up before the game.
And they way he ended up playing no one had any clue about how much he'd suffered before tipoff and how much he was still bothered. He played a series high 40 minutes, scored 15 points on 6-for-7 shooting overall, even hit 3-of-4 free throw attempts and pulled down 11 rebounds.
Afterwards he shrugged off any attempt to label his efforts heroic.
"Man, don't think I'm a hero or anything," he laughed, "it's just modern medicine, mate."
Whatever it was the Thunder will take it and now the team so many questioned during the regular season is back in the Western Conference Finals for the fourth time in six years.


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Lunches and…
May 28, 2010
Hello. I hope everyone is well. This is a quick blog but I will try to be back again soon. I have tried some new items lately and I cant wait to blog about them. We are now seriously counting down for the big move. Time is going so fast and we are so excited!!
I have had a couple really great lunches lately and I thought I would share.
The BEST Chinese food I have had in a very long time. Broccoli in Garlic Sauce with steamed rice from a small place downtown. So good that I had to go back a few days later and get it again.
Salad with veggies and Roasted Veggie Soup with a Tazo peach tea enjoyed outside in the sunshine. The perfect, most delightful lunch.
Rusty! He is the doggie of my in-laws and we got to visit him recently. He is so sweet and funny.
I have been listening to a lot of Laura Marling lately. She is amazing!
Happy Accident
May 14, 2010
So last night I was super eager to make homemade veggie burgers from a vegweb recipe. The recipe called for Gimme Lean Hamburger flavored crumbles. Of course the store only had sausage flavor so I ended up buying another fake meat brand. The crumbles wanted to crumble not form into patties. I almost gave up and threw it out altogether. Then I realized I could make it into my mom's sloppy joes! I just threw in ketchup, mustard, and brown sugar. Delicious! It was so yummy and it tasted just like my mom's recipe without the cow. Cooking is art. You have the freedom to be creative and impromptu as you wish. Last night's dinner was certainly a happy accident.
Fresh corn cut from the cob sautéed with a little Earth Balance and salt/pepper…The BEST!
The meat-free sloppy joes along side a baked sweet potato & corn. Really tasty. I'm definetly making this again.
May 13, 2010
I pretty much eat the same thing each morning/afternoon. My schedule can be pretty random. If I don't have to wake early for a tour I usually sleep in. So breakfast can easily become brunch or lunch. I normally recommend never to eat the same foods over and over. But I love this combination so much that I have eaten it at least 4 days a week for the past year. I call them breakfast burritos but it's really just lots of sautéed peppers and mushrooms wrapped in spicy tortillas. It's so delicious and filling.
Veggies cooking. It seems like a lot but they get smaller plus there is nothing wrong with eating lots of veggies. 🙂
I started out (a year ago) eating burritos with cheese and eggs. Then no cheese. Then no eggs. Now its just tons of veggies. I really need to add some greens to the meal. My journey with healthy food is always progressing. It's really wonderful when you begin to allow yourself to change.
Coffee Perfection!
May 5, 2010
I am a serious coffee lover. I like a medium roast with a little sweet cream. I used to drink the super sweet creamer with high fructose corn syrup. (ick!) Then I switched to Organic dairy creamer. From there I used Silk soy creamer. Although this is a very tasty creamer I wanted to get away from soy products. I have hypothyroidism and there are concerns that soy is not so good for me. So the next step in my journey was So Delicious Coconut Milk creamer. Dairy Free, Soy Free, and so yummy! It is true coffee perfection. I am now addicted and in coffee bliss each morning.
I got this super cute Snoopy coffee mug at a garage sale last weekend for 10 cents.
I LOVE coffee mugs!
"I hate it when it snows on my french toast!"
Still crazy for Silversun Pickups this week
Weekly Beauties…
May 3, 2010
There are a lot of little beauties that have made me very happy in the past week and I would like to share them with you:
This band
Trent has loved this band for a while now. I listened but nothing ever clicked until this week. I am now fully obsessed with them. Their music is intense and really exceptional. Their album "Swoon" has been on serious repeat.
I had lunch with my good friend Abby today. We chose Indian food and it was so delicious. I was happy to have lots of leftovers to enjoy for dinner.
Pineapple makes me very happy. It is now in season and so heavenly.
I eat so many pineapples in the summer that I have my own system of cutting them in record time. Fresh is always better than the pre-cut.
I cannot wait to wear these dresses!
Recent very lucky garage sale finds:
Great condition, my size, only $2!
Perfect for my new Chicago kitchen!
I found this fabric last week. I've been making it into very cool crafts.
Best cat ever. He always makes me happy.
Have a lovely week! Good luck with finals to my school friends!


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Thanks to our modern production plant, we are able to mount components according to your specifications. It depends on the requirements and the scope of the order whether your components are mounted by an island assembly or produced by a line production. Both procedures can be realised by us.
Our flexibly designed assembly workstations are equipped with state-of-the-art technologies. The workstations are individually arranged according to requirements in order to carry out an adequate production/ assembly of both customer tools/ appliances and those developed by us.
The so-called FMEA (Failure mode and effects analysis) enables an accurate definition of the assembly process as well as an adequate release according to the requirements of the customer. Since the assembly of components is currently a manual activity, we have developed our "Doku Soft Traceability System" in order to document and record all work steps. Thus, we can guarantee our customers a complete retraceability.


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Hello All,
I have a P220 Stainless Elite that I had CeraKoted at my LGS. Why? it had significant pitting under the old [rotten] wooden grips.
This pitting, and the rotten grips, was the only major damage- and resulted in me buying the pistol for around $700. don't judge me!
I fit the slide/frame again, and it took some work for the slide to move smoothly.
That got me to thinking about the inside of the frame and polishing.
is there enough side contact on the sear/hammer/trigger bar/slide stop/etc that I should polish the contact areas of the inside of the frame, to maintain the excellent trigger feel it has?
Or, is there not that much contact to begin with?
Thank you for your insights.
Sig P226, P220 Carry Stainless Elite, and a bunch of non-sigs.
If it still has a good trigger feel, I would just put some oil or grease on the areas that make contact and not worry about it.
"I drank what?" - Socrates
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Blanton (1-1, 2.35 ERA) went seven innings in his first start of the year (second appearance). He allowed one run on three hits and one walk. He outpitched Marlins starter Mark Buehrle (0-2, 3.65 ERA), who allowed three runs on eight hits over 6.1 innings. New Phillies closer Jonathan Papelbon came on in the ninth and, despite allowing two hits, closed the door to get his first save at Citizens Bank Park as a Phillie.
The Phillies did not have a base runner their first time through the order but that did not last long. Shane Victorino lead off the fourth inning with a 367 foot shot into the wind in left field that landed in the seats in front of Harry the K's. After a Jimmy Rollins single and a Hunter Pence double, Rollins was thrown out at home on a base running blunder. John Mayberry, Jr. came up with two outs and drove Pence home to give the Phillies a 2-0 lead.
Miami would get one right back after Omar Infante (yes, the same guy who hit two home runs on Monday) doubled to deep left field. John Buck would single him home to cut the Phillies lead in half in the top of the fifth.
The Phillies caught a break in the top of the seventh when Ty Wigginton appeared that he would pop out to the catcher Buck in foul territory. Fortunately for the Phillies, Buck got hesitant as he got closer to the Phillies dugout and dropped the ball. Wigginton would proceed to deposit the next pitch into the left field seats for a 415 foot moon-shot into the wind. Chad Qualls and Papelbon would close the doors for the Phillies and secure the win.
The Phillies get right back at it tonight at Citizens Bank Park as they welcome the New York Mets to town.
-Steve Dolan
Follow Steve on Twitter @SDolan3
Follow Whiz Wit on Twitter @WhizWitSports


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- "Filth, you will pay for your insolence."
"Insolence! We are pirates! We don't even know what that means."
- ―Darth Maul and Hondo Ohnaka
Pirates were individuals who engaged in the criminal activity known as piracy. Such acts included hostage taking,[1] and theft of cargo.[2] Notable pirates include Hondo Ohnaka who had dealings with the highest levels of leadership of both the Galactic Republic and the Confederacy of Independent Systems during the Clone Wars, and those led by Q'anah, who were thwarted by Wilhuff Tarkin during his tenure with the Outland Regions Security Force of Eriadu. Pirates were sometimes associated with bounty hunters.[3]
Non-canon appearancesEdit
- LEGO Star Wars: The Freemaker Adventures – "The Test"
- LEGO Star Wars: The Freemaker Adventures – "The Storms of Taul"
- LEGO Star Wars: The Resistance Rises – "Hunting for Han"
- LEGO Star Wars: The Force Awakens
Notes and referencesEdit
Community content is available under CC-BY-SA unless otherwise noted.


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Supervisor Safety TrainingWritten by Shirley Parker
Supervisory responsibilities for safety tend to be burdensome. A supervisor's training will encompass many areas and may last from one day to a week or several weeks, when all class hours are totaled. Classes may cover walking and working surfaces, exits from buildings, confined spaces (where needed), machinery, and electrical safety. These and other required topics, including ergonomics and protection of hearing, would generally meet a 30-hour objective required by OSHA.
On the other hand, a one-day class may cover site surveillance and assessment, enforcement of safety and environmental conservation rules, and an employer's liability for infractions. A great deal of whatever a supervisor learns in training must be taught to whichever group of employees is affected by the specific safety hazards. Added to these responsibilities may be public information and media communication, although these duties will often be the bailiwick of a separate staff in a large company.
A supervisor's safety knowledge and her attitude towards enforcement of the training she provides has a definite effect on morale, on accident-free days, and the cooperation of the staff, not to mention the bottom line. Employers do not like to be held legally liable for mishaps in the workplace, so a good safety supervisor is worth her weight in gold or any other precious metal.
Training Available for Hazardous Waste and Emergency Procedures
If local resources can't provide them, an online search will bring up school locations where supervisors can attend safety training and learn emergency procedures, such as First Aid for injuries and CPR. Often, the training is needed to be in compliance with state and federal laws, especially when hazardous materials handling and disposal are on that list. While a supervisor may need training to enter confined spaces, that specialty is often best left to full-time rescue personnel, or to others who may be more limber.


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Ulog #03 : Harvesting rambutan fruit in my garden
4 comments
5811 months agoUlogs
Hi Uloggers
Today I go to my own garden again. This month is a big harvest for all the fruits in my garden. Almost all the trees from the fruits that I have planted before now have fruit and even more. And today I am harvesting rambutan and langsat fruit, a little tired when picking it but this fruit is really delicious when consumed.
I feel very happy and happy. I sold some of the fruits that I harvested and partly I distribute them to my neighbors and I consumed them too. It's great when we can share with our loved ones.
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Vacation Bible Camp will be held the week of August 13-17 from 9am to 12 noon each day. Incoming kindergarten through 4th grade students are invited to participate. Participants do not need to be enrolled in Sacred Heart School.
The camp will be run by Mrs. Kirwan and her assistant, Sophie Burroughs. Middle school and high school students are invited to earn service hours as helpers. Please contact Mr. Burroughs to volunteer.
The cost is $125 per child and includes a snack. Payments should be made at the school office or dropped in the Drop Box to the left of the front doors of the school. Assistance is available.


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To order images and/or obtain permission to use them commercially, please contact the KSHS Reference Desk at email@example.com or 785-272-8681, ext. 117.
For more information see the Copyright and Permission FAQ.
This is a carte-de-visite showing Running Bull, possibly a member of the Sioux tribe.
Creator: Cururn
Date: Between 1880 and 1889
Item Number: 303248
KSHS Identifier: DaRT ID: 303248
Collections - Photograph
Date - 1880s
Objects and Artifacts - Communication Artifacts - Documentary Artifact - Photograph - Carte-de-visite
People - American Indians - Tribes - Sioux
Places - Other States - New York - New York City
Type of Material - Photographs - Format - Cart-de-visite


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Roast rabbit with fondant potatoes
- Serves: 4
- Cook Time: 25 minutes
- Prep Time: 20 minutes plus one hr for marinating rabbit
- Effort: medium
- 2 rabbit, each about 1.2kg, trimmed and jointed
- 100 ml olive oil
- salt, and freshly ground black pepper
- bunch of thyme
- 2 large potatoes, peeled and cut into ovals, 1.5cm thick
- 120 g unsalted butter
- 160 g pancetta, or smoked bacon lardoons
- 3 tbsp sherry vinegar
- 1 small Savoy cabbage, (or substitute spring greens) finely shredded
- 100 ml madeira
- 150 ml chicken stock
- 2 shallots, finely chopped
1. Marinate the rabbit by drizzling over half the olive oil. Season and scatter with thyme. Leave for approximately 1 hour.
2. Set the oven to 220°C/gas 8. Heat a heavy based frying pan and brown the rabbit pieces over a high heat. Remove from the pan and place into a roasting pan. Set aside.
3. Meanwhile place the potatoes in a frying pan, in a single layer, cover with water and add half the butter. Cook over a high heat until the potatoes are soft and all the water evaporated - they should now be a lovely golden colour.
4. Transfer the rabbit to the oven and roast for 6-8 minutes. In the original pan used to fry the rabbit pieces, fry the pancetta until crispy and add the sherry wine vinegar. Put the finely shredded cabbage or greens in a bowl, pour over the hot dressing and toss well. Put the pan back on the heat and add the Madeira and stock. Boil until a little syrupy and whisk in the remaining butter.
5. To serve place a slice of potato on each plate and cover with a mound of the finely shredded greens. Top with the rabbit, pour over the sauce and serve immediately.
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WSOP Updates – Event #37, $2,000 PLHE — Yuval Bronshtein Heads Pot-Limit Final Table
45 players returned to action on Saturday in Event #37, $2,000 Pot-Limit Hold 'Em made a somewhat anonymous entry to the tournament floor, buried by the sea of entrants in the day's no-limit hold'em tourney. The 45 were the survivors from an initial field of 599, with all already assured of cashing as they took their seats.
Day Two moved at a decent pace with players busting on a regular basis. The day's first round of play saw the elimination of 15 players. Thayer Rasmussen was the last player to hit the rail before the first break, collecting $6,541 for his efforts.
As Round 13 got underway, there were plenty of interesting hands, but Kelly Garrett's hurt a bit more than most. Praz Bansi made a raise from middle position and Garrett called from the big blind. The flop came J-8-2 and Garrett checked. Praz bet out 15,000 and Garrett came over the top for a total of 33,000. Praz hesitantly called with the "Hammer" (7-2), for bottom pair, which was still ahead of Garrett's A-Q. The turn brought yet another deuce, finishing Garrett's day in 28th spot ($6,541), while Praz jumped up in chips to 168,000. Unfortunately for Bansi, his luck would run out and he finished in 16th place.
Two of the biggest remaining names, Daniel Alaei and T.J. Cloutier, also saw their final-table hopes dashed. Alaei's day ended when he ran into Jordan Smith's pair of tens. Despite having a ten himself, Alaei had a lower kicker and was bounced in 20th. The wily Cloutier had an up-and-down day that in saw him make another run at a World Series of Poker final table, but it simply wasn't meant to be. Cloutier's day ended when big stack Yuval Bronshtein called his all-in bet. Cloutier made a pair of aces on the turn, but the river gave Bronshtein a set of tens, eliminating Cloutier, who finished in 11th for $10,902.
The unfortunate final-table bubble boy was Jordan Smith, who had his pocket jacks cracked by Gioi Luong's runner-runner two pair. Smith earned $10,902 for his play.
Going into Day Three and the final table, Bronshtein has the chip lead with 516,000, but he is followed closely by Greg Hopkins with 454,000. The complete final table with seating assignments and chip counts is as follows:
Seat 1: David Zerrin — 238,000
Seat 2: Ray Coburn — 100,000
Seat 3: Pete Lawson — 198,000
Seat 4: Gioi Luong — 240,000
Seat 5: Yuval Bronshtein — 516,000
Seat 6: Bryan O'Donnell — 179,000
Seat 7: Robert Collison — 197,000
Seat 8: Jason Newburger — 278,000
Seat 9: Greg Hopkins — 454,000
Check in with Pokernews.com's 'Live Reporting' of Event #37, $2,000 Pot Limit Hold 'Em, at 2pm PDT Sunday afternoon for all of the final-table action.


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MWD needs your input.
In the interest of continuing this blog and be interesting to readers, I'd like to see what you, the reader, would like to know about the advertising world.
I'll choose a new topic weekly. It can be related to general education of the business, or to what's going on in the current news to make it relevant.
Looking forward to hear from you soon!


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April and I were talking to a friend about her grandfather the other day. I don't remember why but April asked why her grandfather moved to a certain area of Mississippi or something like that and the girl said,
"He worked on rockets."
"Like plane engines?"
"Like NASA."
"In Mississippi?"
That's not exactly how it went, but it was similar. And, it made me think back fondly of school field trips to southeastern Mississippi where we would learn about spaceship engines at the John C. Stennis Space Center.
The Stennis Space Center is where the rocket engines for every manned NASA Apollo and shuttle flight into space were tested. It is also where next-generation engines are being tested for the next era of space travel, specifically deep-space travel.
So that's cool. Rocket scientists in Mississippi. There was a saying in the 1970s, "If you want to go to the moon, you first have to go through Hancock County, Mississippi." Pretty funny considering you can go absolutely anywhere else without going through Hancock County.
In 1961, exactly five months after John F. Kennedy decided he wanted a man sent to the moon and brought back safely by the end of the decade, NASA announced the building of the center. Fewer than five years later the very first Saturn V rocket was tested as then then-named Mississippi Test Facility.
If you are unfamiliar with the Saturn V, it's that giant missile Tom Hanks, Bill Paxton and Kevin Bacon sat atop in the movie Apollo 13.
That ship may look really big, but most of it is just rocket. The actual ship was this small:
And the part the astronauts spent most of their time in was this size:
One of the coolest moments of my entire childhood was sitting in a real apollo capsule at Space Camp in the fifth grade. One of the least cool moments of my childhood was when I was at the Stennis Space Center, surrounded by awesome space souvenirs, and I bought a little magnetic puzzle that had nothing to do with space. That or the time I picked my nose all the way through the introduction part of joining Mulberry Springs Baptist Church in Hallesville, Texas. The whole time. The pastor was trying to introduce my mom and dad to the congregation. I was trying to introduce my finger to boogers.
Back to Stennis.
The center is one of 14 NASA visitor centers in the country and has some really cool tour and museum components. I'm planning on taking April down to South Mississippi for a tour of the space center and then maybe a Lazy Magnolia brewery tour. It will be a fun day trip. The museum was really cool when I was a kid and they've added a 70,000 square-foot exhibit space since then. Go check it out.


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Wurf Boards are Shipping!!!!
Hello Wurfers:
We received our first shipment of Wurfs! We were thrilled to see them arrive and have started shipping them out to US customers.
With all new productions though,... Read more
Wurf Boards Arrived at the Port!
Future Wurfers:
Thanks for your patience! We are very excited to announce that the Wurf Boards have arrived at the port and will be at our warehouse by week's end.... Read more
Shipping Update
To our Future Wurfers:
We are putting our best foot forward to make sure you get the perfect board. Revolutionary and unique, the Wurf Board has taken a lot of... Read more
Shipping Update and Contest Details
Hello Future Wurfers,
We are very excited about our success on Kickstarter and we are working very hard to get the Wurf Boards shipped out to you!
As we stated... Read more
New Year Resolution — Help Your Friends Get on a Wurf Board
Work-at-Home Warriors Love the Wurf Board
Given all the love we get from our early adopters like Allena Tapia who writes at About.com:
- I agreed to try out a Wurf Board... Read more
Winning Design for T-Shirt Contest
Here's the Vote Winning T-Shirt
Thanks for voting, here's the new reward for your vote winning 100% cotton T-Shirt:
We are offering three 100% cotton T-Shirt versions:
- Regular — $23... Read more
Thank you for your gift to school children — 78 Wurf Boards so far!
Merry Christmas to our wonderful supporters!
We are so grateful to have a growing family on Kickstarter, we are now up to over 780 supporters. That means we are going... Read more
We Did It! — Over 100% Funded — Big Thanks & PRODUCT UPGRADE FOR EVERYONE!!!
Upstanding Backers!
We've bounced over our funding goal—Thanks to all of you! We're sharing the joy by giving every backer freesix-month access to the Wurf Board at-desk... Read more
New Wurf Board Design
Cool new designs to rate — this is the semi-finals! Like the design not the color? Let us know. Go here: DesignPoll.Wurf.com.
Help us deliver the best Wurf Boards —... Read more
Cool New Wurf Board Art — Design Contest
View Design.Wurf.com to see cool designs for upcoming new reward for a limited edition large Wurf Board sporting a cool new design on the Wurf Board surface.
Please post the Design numbers... Read more
New batch of Wurf T-Shirt designs for your input
Vote on the next batch of cool T-Shirt designs at T-ShirtPoll.Wurf.com. See all the designs being submitted at T-Shirt.Wurf.com.
Poll for T-Shirt design contest
We'd love your help choosing T-shirts! Ck out our T-ShirtPoll.Wurf.com contest—vote and comment. If we left out one you like on T-Shirt.Wurf.com, let us know. Thanks!
We're running a Wurf T-Shirt design contest
We're going to be adding a T-Shirt reward option and have started a contest to design a cool T-Shirt for the Wurf Board backers to proudly wear. You can see... Read more


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No problem! From now on you can design your own website within a few minutes without programming knowledge. Just select your industry and the topic you want, enter content, possibly add images - done!
With just a few steps, your own, modern website. Whether for your company or your last vacation trip
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Planning a visit to DMZ and JSA in Korea? Here are 13 things you need to know before you go to Korean DMZ, the border between North and South Korea.
Tag: historical sites
First-Time Traveler's Guide To Seoul
"You do not travel if you are afraid of the unknown, you travel for the unknown, that reveals you with yourself." – Ella Maillart First time traveling in Seoul? If you have no ideas where to go or what to do in Seoul,
The Scars of Jeju Island: The Jeju April 3 Incident
This is a travel diary of a Hyoseung Allyson W from Jeju Island. The April 3 Incident To me, Jeju used to be a beautiful island where everybody wanted to visit for their either romantic or exciting vacation. Of course,


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Want to get your feet wet in the wonderful and eco-conscious world of socially-responsible investing? You're not alone. Back in the day, impact investing was only available for big-money investors who are willing to invest large amounts.
But we are now in the realm of environmentally-friendly living. Non-biodegradable synthetic plastics are now commonplace in the Earth's most beautiful oceans. Despite what naysayers may say, climate change is here to stay. The blazing hot summers and irregular frigid winter are, sad to say, just the tip of the (disappearing) iceberg.
We all need to be more responsible for our actions, which include our investing activities. The best socially-responsible Robo Advisors will help you to be a more eco-friendly investor without the high risks and huge fees. Want to invest in socially conscious stocks in the world of alternative energy, disease eradication, or healthy living? We have answers for you right here.
Are you new to the world of automated investment services? Are you a seasoned investor and want to give impact investing a shot? Here are the best green Robo Advisors that will make it easy for you to start.
|Robo Advisor
|Expert Rating
|Visit Site
| 100% Impact Investing
Low Minimum Deposit
East to Use
Read Review
|Visit Site
| Free premium features
$0 account minimum
Easy to use
Read Review
|Visit Site
| Easy to Use
Fully Automated
High Fees
Read Review
|Visit Site
Swell Investing
Invest in Progress
Swell Investing is a socially-responsible Robo Advisor that is backed by one of the most well-known insurance providers in the USA. They allow small investors to invest on a varied selection of 'green' stocks for a low minimum amount of $50. Considering that responsible investing was previously limited to high-value ETFs, the low minimum deposit is enticing enough for the average Joe.
Swell Investing is easy to use and offers the usual IRA and taxable accounts. But the highlight of the service are the socially-responsible stocks and ADRs on green energy, clean water, and healthy living. The service also includes automatic deposits and portfolio rebalancing. This service is not perfect; the management fees are on the higher end of the spectrum. But for automated sustainable investing, Swell Investing is one of the best choices on the market.
Investing on Autopilot
If you sign up to Wealthsimple using our link, your first $10,000 investment will be managed for free! There's no catch; just sign up using our link and your first $10,000 investment will be managed free of charge!
Wealthsimple is a traditional Robo Advisor. It offers the usual SEP IRA, traditional IRA, Roth IRA, and Rollover IRA accounts. But it also offers halal-based investing opportunities along with socially-conscious or green stocks. The Wealthsimple Basic service will charge ZERO advisory fees for the first year and will only cost you 0.5% for accounts above $100,000. Although Wealthsimple is not intended for hands-on investors, it remains a solid choice in the world of eco-friendly investing.
Polaris Portfolios
Invest for Life
Polaris Portfolios is a fully-automated Robo Advisor, making it an excellent choice for hands-off investors. It does, however, require a higher minimum deposit and comes with slightly higher management fees as well. But the service will charge zero trading fees and transaction fees, and you can open multiple investment accounts.
Polaris also offers unlimited email support to offer added peace of mind. But Polaris is also known for offering values-based portfolios. This will give you the chance to put your money on green companies and socially-responsible endeavors that focus on sustainability and positive social impact. Even though Polaris isn't the best choice for small investors, the service is an easy way to experience the finer points of responsible investing.
More Green Robo Advisors for Impact Investing
In addition to our favorites above, there are a number of other Robo Advisors that offer socially-responsible impact investing options.
Earthfolio is a smart and low-cost option in SRI automated investing. This Robo Advisor is unique because it allows you to invest exclusively in companies with strong ESG or Environment, Social, and Governance practices. This includes clean energy, conservation, equal employment, diversity in hiring, financial transparency, and board independence. It is free to open an Earthfolio account and the service charges a modest annual fee of 0.50%.
OpenInvest is also an SRI Robo Advisor that offers investment portfolios with a powerful social impact. The service starts by answering a questionnaire on the causes that you are passionate about such as taking down big tobacco, fighting guns and violence, reducing carbon emissions, or protecting global forests. The service will automatically build and manage a diversified portfolio while giving you updates on your social impact. OpenInvest requires a minimum deposit of $3,000 and will charge a 0.50% annual fee.
Betterment has recently unveiled socially responsible investing choices that clients can easily select and add to their existing portfolio. The SRI portfolio of Betterment is composed of ETF's from iShares, with more SRI funds to be integrated in the near future. Betterment claims that socially responsible investing is an $8 trillion category as more and more clients are demanding the availability of SRI approaches in their investment activities. Betterment is already one of the best Robo Advisors that offers superior flexibility with no minimum deposit.
Wealthfront is also opening new doors in socially responsible investing. Existing clients can now remove any security that doesn't fit the mold of ethical investing. Prime examples are securities in the fossil fuels, weapons, tobacco, and deforestation industry. Any client of Wealthfront that qualifies for Stock-level Tax-Loss Harvesting or Smart Beta can tell Wealthfront which companies they do not want to invest in. While Wealthfront's options for impact investing are lacking compared to many other Robo Advisors, we're glad to see they're at least making some sort of effort. We'd like to see more options from them in the near future.


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Sharad Patel
Autogenous bone: is it still the gold standard?
Specific Treatment Considerations. When the height of the residual bone in the posterior maxilla is considered insufficient for reliable implant placement, a sinus grafting procedure is considered the treatment of choice. Cawood and Howell in their classification of resorption patterns demonstrated bone resorption develops tridemensionally. Additionally, the atrophic posterior maxilla should be evaluated and classified in terms of not only the residual bone height and width, but also the residual vertical and horizontal intermaxillary relationship, because if sinus grafting is only performed and there is tridimensional bone loss, the implants may be placed in a palatal position. Correction of deficient ridges to achieve an optimal prosthetic result can be performed in different ways. It is essential to define the final prosthetic objective using clinical, radiographic and laboratory information prior to selecting the most adequate surgical procedure.