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Patient Safety and Quality in Pediatric Hematology/Oncology and Stem Cell Transplantation pp 183-204 | Cite as
Healthcare-Associated Infections in Pediatric Hematology-Oncology
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Pediatric hematology-oncology and hematopoietic stem cell transplant (HSCT) patients are at high risk of infections, including healthcare-associated infections (HAIs), resulting in a need to prevent these occurrences when possible. Central line-associated bloodstream infections (CLABSI), Clostridium difficile infection (CDI), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and respiratory viral infections are of particular concern, and the incidence, definition, and other features are reviewed. Currently, standard prevention guidelines exist for selected HAIs, and so the prevention approach for each infection must be considered separately. Prevention strategies have emerged through collaborative efforts, as well as measurement of both process and outcome data. Measurement includes surveillance of infection occurrence; identification and reporting of prevention methods, such as bundles; and the outcomes associated with these approaches. These prevention and measurement approaches are only successful when approached collaboratively with engagement across the entire healthcare team. Through continued measurement and process improvement based on the data collected, more sustainable approaches to infection prevention can be developed. With systematic effort, the occurrence of HAI should be reduced, and patient harm will be prevented.
KeywordsHealthcare-associated infection Quality improvement Patient safety Central line-associated bloodstream infection Ventilator-associated pneumonia Catheter-associated urinary tract infection Clostridium difficile Root cause analysis Collaborative
In the last decade, advances in cancer therapy have led to improved survival in children and adolescents with malignant disorders. As cure rates improve, treatment-related toxicity, especially infections, accounts for a greater proportion of morbidity and mortality. Pediatric hematology and oncology patients are often highly susceptible to infection. Those with medical devices, such as indwelling central catheters, and those with intermittent or chronic neutropenia are particularly at high risk of healthcare-associated infections (HAIs) such as central line-associated bloodstream infections (CLABSI), Clostridium difficile infections (CDIs), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and respiratory viral infections. In the past, infectious complications of therapy for oncological and hematological disorders were regarded as largely unavoidable. It is now recognized that many, although not all, of the most common infections in this population are preventable. Collaborative quality improvement efforts have led to effective strategies to reduce rates of HAI and improved outcomes in these populations.
Healthcare-Associated Infections
Central Line-Associated Bloodstream Infections (CLABSI)
Pooled means of laboratory-confirmed permanent and temporary central line bloodstream infections, by type of unit
Overall pooled mean CLABSI
Pooled mean CLABSI—permanent central line days
Pooled mean CLABSI—temporary central line days
Adult general medical/surgical inpatient
Adult medical/surgical ICU
Adult general hematology-oncology ward
Adult HSCT ward
Pediatric general medical/surgical inpatient
Pediatric medical/surgical ICU
Pediatric general hematology-oncology ward
Pediatric HSCT ward
Microorganisms colonize most central lines, often in as a little as a day, by (a) migration from the skin insertion site along the external surface of the catheter, (b) introduction into the hub lumen during manipulation of the catheter or by exposure to contaminated infusates, or (c) hematogenous spread from a focal infection [3]. Thrombin covering the intravascular portion of the catheter and the biofilm produced by many microbial pathogens promotes the adhesion of pathogens. The risk of subsequent bloodstream infection is dependent on both the number of organisms and their intrinsic virulence. Host, underlying disease, and treatment characteristics also contribute to the risk of CLABSI [4, 5].
Criteria for catheter and mucosal barrier injury laboratory-confirmed bloodstream infections
Laboratory-confirmed bloodstream infection (LCBI)
(1) A recognized pathogen identified from ≥1 blood cultures
(2) Fever, chills, or hypotension in association with the same common commensal bacteria being obtained from ≥2 blood cultures drawn on separate occasions
(3) Fever, hypothermia, apnea, or bradycardia in a patient ≤1 year of age in association with the same common commensal bacteria being obtained from ≥2 blood cultures drawn on separate occasions
In each case, the organism identified from blood should not be related to an infection at another site (i.e., the infection represents a primary bacteremia), and criterion elements must take place 3 days before to 3 days after the collection date of the first positive blood specimen
Central line-associated bloodstream infection (CLABSI)
A LCBI that develops in a patient with a central line in place for >2 days before the onset of the infection
Catheter-related bloodstream infection (CRBSI)
A LCBI with additional laboratory evidence that identifies the central line as the source of the bloodstream infection (e.g., differential time to positivity of blood cultures)
Mucosal barrier injury LCBI
(1) That meets LCBI criteria 1 and ≥1 blood specimen is positive for a select group of recognized intestinal organisms, in association with:
a. A history of allogeneic HSCT within 1 year and Grade III or IV gastrointestinal GVHD) or ≥1 liter diarrhea (≥20 mL/kg in patients <18 years of age) in a 24-h period on or ≤7 days before the collection date of the first positive blood specimen
b. A history of ≥2 days of an ANC or WBC <500 cells/mm3 on or within 3 days of the collection date of the first positive blood specimen
(2) That meets LCBI criteria 2 and ≥1 blood specimen is positive for viridans group streptococci only, in association with:
a. A history of allogeneic HSCT within 1 year and Grade III or IV gastrointestinal GVHD or ≥1 liter diarrhea (≥20 mL/kg in patients <18 years of age) in a 24-h period on or ≤7 days before the collection date of the first positive blood specimen
b. A history of ≥2 days of an ANC or WBC <500 cells/mm3 on or within 3 days of the collection date of the first positive blood specimen
(3) A patient ≤1 year of age who meets LCBI criteria 3 and ≥1 blood specimen is positive for viridans group streptococci only, in association with:
a. A history of allogeneic HSCT within 1 year and Grade III or IV gastrointestinal GVHD or ≥1 liter diarrhea (≥20 mL/kg in patients <18 yrs. of age) in a 24-h period on or ≤7 days before the collection date of the first positive blood specimen
b. A history of ≥2 days of an ANC or WBC <500 cells/mm3 on or within 3 days of the collection date of the first positive blood specimen
Clostridium difficile Infection (CDI)
C. difficile is the single most common organism causing HAI in the United States, with an estimated incidence of 95.3 infections per 100,000 persons overall and 6.3 per 100,000 children under 18 years of age [11, 12]. C. difficile is a Gram-positive, anaerobic, spore-forming bacillus. Intestinal colonization occurs when infectious spores, which may persist for long periods in the environment, are ingested. Some strains elaborate two homologous exotoxins, toxin A and toxin B,which bind to and damage intestinal epithelial cells and incite strong inflammatory responses [13]. North American pulsed-field gel electrophoresis type 1 (NAP1) PCR ribotype 027 strains of toxogenic C. difficile, which express more toxin A and B than other strains and an additional binary toxin, emerged in the early 2000s. Now commonly found in North America, these strains are associated with more severe disease in adults, but it is not yet clear whether they are more pathogenic in either children or cancer patients [14].
In order for CDI to occur, patients must be colonized with toxogenic C. difficile and undergo some alteration in the gastrointestinal microbiome that promotes decreased microbial diversity [13]. The most commonly recognized risk factor for CDI is antibiotic use; others include antineoplastic chemotherapy, the use of proton pump inhibitors, gastrointestinal surgery, inflammatory bowel disease, and immunocompromising conditions [15]. Adults with cancer and recipients of HSCT are at significantly greater risk of CDI than the general hospital population, with rates ranging from 3.4% to 27% [16]. Disease manifestations range from mild diarrhea to fulminant pseudomembranous colitis. Complications such as toxic megacolon, bowel perforation, and sepsis are responsible for an estimated fatality rate of up to 15% in adults [12]. Malignancy is also a strong predictor of recurrent CDI. Most children with healthcare-associated CDI have underlying medical comorbidities, with malignancy being the most common. Up to 25% of cases of CDI in hospitalized children occur in those with cancer, a rate tenfold higher than that observed in children without cancer [17, 18]. Boyle reported 17% of pediatric HSCT recipients older than 1 year of age developed CDI within 100 days of transplant (20/10,000 patient days), significantly higher than that the rate observed in adult recipients [19]. Severe and complicated disease appear to be less common in children than adults, but more frequent in children with cancer than those without malignancy [15, 16, 20].
The NHSN defines healthcare-associated CDI as a positive test for toxin-producing C. difficile in an unformed stool specimen and/or gross anatomic or histopathological evidence of pseudomembranous colitis, with disease beginning >3 days after admission to a healthcare facility [21]. This and other clinical and surveillance definitions have significant limitations that may affect estimates of the incidence of CDI in pediatric oncology patients. Over half of young children, especially those <2 years of age, and almost a third of pediatric oncology patients may be asymptomatically colonized by C. difficile, often for long periods of time [22, 23, 24]. Some investigators have suggested that sensitive molecular diagnostic tests, such as nucleic acid amplification of toxin A and B genes, are more likely to overestimate the incidence of CDI than older assays because these are more likely to identify the clinically inconsequential carriage of C. difficile [22]. Viruses and other gastrointestinal co-pathogens are also detected in as many as 80% of children, including immunocompromised children with CDI, making it difficult to judge the contribution of each potential pathogen to diarrheal disease [25, 26]. Importantly, however, patients who are colonized with toxogenic C. difficile may still represent a source of environmental shedding and transmission of infectious spores. Judicious use of antimicrobials, infection prevention precautions, and environmental cleaning are the mainstays of CDI prevention in healthcare settings.
Ventilator-Associated Pneumonia (VAP)
National Hospital Safety Network surveillance definition for pneumonia in immunocompromised patients
Diagnostic imaging
≥2 serial chest imaging studies at a ≤ 7-day interval demonstrating at least one of:
• New or progressive and persistent infiltrate(s)
• Consolidation
• Cavitation
• Pneumatoceles in infants ≤1 year of age
In patients without underlying pulmonary or cardiac disease, a single unequivocal chest imaging study is acceptable
Clinical findings
At least one of:
• Fever (>38.0 °C)
• New onset of purulent sputum, change in character of sputum, increased respiratory secretions, or increased suctioning requirements
• New onset or worsening cough, dyspnea, or tachypnea
• Crepitations or bronchial breath sounds
• Hemoptysis
• Pleuritic chest pain
Laboratory tests
At least one of:
• Positive blood culture not related to another source of infection
• Positive pleural fluid culture
• Positive quantitative culture from minimally contaminated lower respiratory tract specimen
• 5% BAL-obtained cells with intracellular bacteria on Gram stain
• Positive quantitative culture of lung tissue
• Histopathological evidence of abscess formation or intra-alveolar/bronchiolar accumulation of PMNs
For viral and fastidious bacterial (e.g., Legionella) pneumonias:
• Positive culture from respiratory secretions
• Positive nonculture diagnostic test from respiratory secretions
• Fourfold rise in paired acute and convalescent serum antibody titers
• Detection of Legionella antigen in urine
For fungal infection:
• Matching positive blood and sputum/ET aspirate cultures with Candida spp.
• Evidence of fungi from minimally contaminated LRT specimen by direct microscopic examination and culture or nonculture diagnostic test
The precise incidence and clinical outcomes of VAP have been difficult to establish because studies have used diverse diagnostic criteria and inconsistently applied these criteria and because diagnostic definitions for VAP, including those reported by the NHSN, have limited sensitivity and specificity [28]. The signs and symptoms of VAP, for example, may overlap with other infections, such as tracheobronchitis, and with noninfectious pulmonary disorders [29]. Reactivation of latent pulmonary or systemic infection, such as cytomegalovirus or tuberculosis, in oncology and transplant patients, including children, may be indistinguishable from VAP. Some features of the current NHSN surveillance definition make its application to children problematic. Respiratory specimens, for example, must be obtained by methods that limit contamination, such as bronchoalveolar lavage, that may have technical limitations and greater risks in young patients [30]. Recognizing the limitation of VAP surveillance definitions, NHSN surveillance began to assess a broader range of ventilator-associated events, including VAP, in adults in 2015 [31]. A pediatric-specific algorithm for VAP is not yet available, but one study that applied adult definitions retrospectively to PICU patients receiving mechanical ventilation suggests that this strategy may be useful [32].
CAUTI rates [1]
Pooledmean CAUTI
Adult general medical/surgical inpatient
Adult medical/surgical ICU
Adult general hematology-oncology ward
Adult HSCT ward
Pediatric general medical surgical inpatient
Pediatric medical/surgical ICU
Pediatric general hematology-oncology ward
Pediatric HSCT ward
The pathogenesis of VAP has not been completely elucidated. VAP may, like conventional pneumonia, result from the inhalation of infectious aerosols or complicate hematogenous bacteremia or fungemia. The presence of the same microorganisms in the oropharynx and in endotracheal aspirates, however, suggests that a frequent and potentially preventable cause of VAP is the aspiration of microorganisms colonizing the endotracheal tube (ET), oropharynx, or stomach [37]. Micro-aspiration of upper airway secretions around the uncuffed ET commonly used in infants and children or through channels formed by folds in low-pressure high-volume cuffed ET may be exacerbated by the impairment of mucociliary clearance and pooling of secretions in the subglottic airway. Risk factors for VAP in children include a prolonged duration of mechanical ventilation, prior antimicrobial exposure, and the use of immunosuppressing drugs, particularly corticosteroids [38]. Additional contributing elements may include the replacement of the usual microbiological flora of the oropharynx and stomach by more virulent species (such as Staphylococcus aureus and Gram-negative bacilli), the contamination of suction equipment (particularly associated with the use of open systems and nonsterile solutions), and the presence of a nasogastric tube, enteral feeding, poor oral hygiene, gastric distension, and positioning (with the semirecumbent position associated with a lower risk of VAP than the supine position). The contribution of each of these elements to the pathogenesis of VAP in pediatric hematology-oncology patients has not been studied; most prevention strategies target multiple risk factors for infection.
Catheter-Associated Urinary Tract Infections (CAUTI)
Overall, urinary tract infections (UTI) are the fourth most common HCA infection in the United States [39]. Almost all are related to catheterization or other instrumentation. Short-term indwelling urinary catheterization may be necessary because of acute urinary retention or obstruction, or the need to monitor urinary output (especially perioperatively, during critical illness, or if receiving large volumes of fluid or diuretics). More prolonged use may be required to promote healing of sacral or perineal wounds or incisions, in incontinent patients or for comfort during end of life care.
The NHSN defines CAUTI as a UTI that occurs >2 calendar days after a urinary catheter is placed and <1 day after the catheter has been removed, if applicable [39]. Rates are generally higher in children than in adults (Table 11.4), but little has been reported on outcomes in children outside of the intensive care setting or in specific populations such as pediatric hematology-oncology and transplant recipients. CAUTI are associated with secondary bloodstream infections, increased hospital stay and costs and, in adults, increased mortality [40, 41].
Most CAUTI are ascending in origin. Uropathogens that colonize the periurethral area adhere to fibrinogen that accumulates on the catheter, multiplying and forming biofilm [41]. Thereafter, bacteria may colonize the bladder, often within days, releasing toxins and proteases that damage urinary epithelium and promote ascension to the kidney and hematogenous dissemination. Up to a third of infections may occur from contamination of the urinary collecting system from exogenous sources, such as the hands of healthcare providers [42]. Efforts to prevent CAUTI have focused on reducing the duration of catheter use and the contamination of drainage systems.
Respiratory Viral Infections
Most respiratory viruses are spread by indirect contact, droplet, or airborne transmission. Sources of infection include other patients, caregivers or visitors, and healthcare providers, who may be asymptomatic or symptomatic, and contaminated environmental sources [43]. Patient factors that increase the likelihood of healthcare-associated respiratory viral infections in pediatric hematology-oncology and transplant patients include their frequent close physical contact with caregivers, young age, lack of previous natural infection or immunization and subsequent acquired immunity, and the presence of primary or secondary immunodeficiency. In the ambulatory healthcare setting, patients may be cared for in extended periods in common areas; the risk of infection is increased when infectious persons are not immediately recognized and when environmental cleaning is inadequate because of time constraints.
Strategies to reduce healthcare-associated respiratory viral infections include transmission-based infection, prevention, precautions, and vaccination. Institutions must provide infection prevention staff, clinical microbiology support, and the supplies and equipment necessary to assess and correct remediable causes of healthcare-associated respiratory viral infections. Risk assessment should inform the development of processes for the surveillance for and management of endemic, epidemic (e.g., influenza), and emerging (e.g., Middle East respiratory syndrome-coronavirus) respiratory infections.
Respiratory hygiene and cough etiquette components
1. Education of staff, patients, and visitors regarding respiratory hygiene and cough etiquette
2. Posted signs instructing patients and caregivers to make healthcare personnel aware of symptoms of respiratory illness
3. Provision of materials for source control (e.g., tissues, alcohol-based hand rub or supplies for handwashing after contact with respiratory secretions)
4. Masking and spatial separation of persons with respiratory symptoms from others in common waiting areas (ideally in a single room, a minimum of 3 ft from others)
5. Observance of droplet and standard precautions by healthcare providers when examining patients with symptoms of a respiratory infection
Few high-quality randomized clinical trials have addressed the effectiveness of masks for the prevention of transmission of respiratory viruses. Existing evidence suggests, however, that both medical masks and respirators are effective. The CDC and other agencies recommend the use of these devices to protect patients and healthcare providers against seasonal influenza and tuberculosis. Clinical trials suggest that face masks provide compliance-dependent protection against infection in the community [44]. For healthcare providers, respirators appear to provide superior protection, but the choice of respiratory protection should be based on availability, etiology of illness, comfort, and the degree of risk.
Healthcare providers should refrain from working when ill with symptoms of a communicable respiratory infection; management policies should support and not discourage this practice. Likewise, visitors with respiratory illnesses should be discouraged from entering healthcare facilities unless this is unavoidable.
Seasonal influenza vaccination of healthcare providers reduces hospital-acquired influenza infections in cancer patients, and most evidence suggests that this practice decreases employee morbidity and absenteeism [45, 46, 47]. The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommends that, unless medical contraindications exist, all healthcare personnel should be vaccinated annually to protect themselves, their families, and their patients against influenza [48]. Similar recommendations exist for the use of tetanus-diphtheria-acellular pertussis (Tdap) vaccine for the prevention of pertussis [49]. These recommendations direct organizations to provide vaccine as part of employee health programs and to make efforts to reduce administrative and financial barriers to immunization [50]. Personnel refusing influenza vaccination for reasons other than a documented medical contraindication should sign a written declination that outlines the risks of vaccine refusal. Influenza immunization of HCP is tracked by the NHSN. During the 2014–2015 season, 88.6% of employees and 84.5% of all healthcare personnel in acute care hospitals received seasonal influenza vaccination, representing a significant increase over historical rates of compliance with vaccine recommendations [51, 52]. Successful strategies to improve compliance with vaccination policies have included education and incentive-based (i.e., reward) systems, but the most effective approaches have been mandatory vaccination policies that require the use of protective face masks or antiviral prophylaxis for the duration of the influenza season or result in the suspension or termination of unvaccinated workers [53]. Some states have enacted legislation to increase healthcare provider immunization rates [54].
Both process (important data elements related to patient care activities) and outcome data must be systematically collected to prevent HAI. Ongoing process and outcome data collection can inform the development of more effective prevention strategies or lead to the modification of suboptimal processes. The latest CDC surveillance definitions should be used to identify the occurrence and rates of HAI within an institution [6]. If ongoing surveillance reveals a sharp increase in infections, standard epidemiological investigation techniques must be used to investigate the outbreak; these methods are beyond the scope of this chapter [55]. Organizations should remain open to reevaluating and improving measures for HAI based on new knowledge. For example, the recently developed definition for MBI-LCBI, clearly differentiating these infections from other CLABSI, is a relatively new outcome measurement that has substantial importance to the pediatric hematology-oncology population.
Prevention bundle elements for CLABSI, CAUTI, and VAPa
Standard Elements
Hand hygiene
CHG scrub
No iodine treatment
Prepackaged or filled insertion cart, tray, or box
Insertion checklist with staff empowerment to stop non-emergent procedure
Full sterile barrier for providers and patients
Insertion training for all providers
Daily discussion of central line necessity, functionality, and utilization including bedside and medical care team members
Regular assessment of dressing to assure clean/dry/occlusive
Standardized access procedure
Standardized dressing cap and tubing change procedures/timing
CLABSI—recommended element
Utilize a system approach to review all hospital-acquired CLABSI
Use aseptic technique for insertion
Avoid unnecessary catheterization
Maintain a closed drainage system
Maintain hygiene
Keep bag below level of bladder
Maintain unobstructed flow of urine
Remove catheter when no longer needed
CAUTI—recommended element
Secure catheter
Readiness to extubate—assess readiness to extubate daily
Head of bed elevation—elevate head of bed to 30–45 degrees
Minimize distribution of the circuit—inspect ventilator circuit for gross contamination daily, and if present, change circuit
Oral hygiene—perform oral hygiene minimally every 12 h
The SPS document lists standard and recommended bundle elements and provides tools for assessing the reliability of these bundles, such as protocols for audits of performance on all SPS Prevention Bundle Standard elements [57, 58]. Institutions can choose to include additional elements if they desire to gather data on other processes, but SPS suggests limiting these to five or fewer so that healthcare staff are not overwhelmed or confused by the number of interventions [57]. For CLABSI and CAUTI, it is recommended that insertion and maintenance bundles be measured separately. SPS recommends performing a minimum of 20 audits per month in order to obtain data frequently enough to rapidly identify barriers to compliance and to make changes in the processes to eliminate these barriers [57]. A 90% compliance rate for bundle data is a common goal within SPS. Organizations using sophisticated electronic health records (EHR) with capabilities to discretely document and subsequently retrieve data may be able to gather some or all data electronically. However, this approach may not be feasible in all settings, and direct observation of bundle elements may identify additional opportunities for improvement that may not be revealed through automated retrieval of data documented in the EHR.
Recommended practices include structured investigation, data collection, and analysis of all episodes of infection. These efforts may be referred to by various names, depending on the organization [e.g., mini root cause analyses (RCA) or line rounds]. Many institutions use this approach, documented most commonly for CLABSI, to retrace every step leading up to the infection and thereby identify improvement opportunities. The goal of this approach is to allow institutions to learn from each and every infection and implement improvements based on these findings. For example, Rinke et al. used a RCA approach to systematically investigate all CLABSI in hospitalized pediatric oncology patients [59]. When a positive blood culture was reported, a multidisciplinary team interviewed care providers and analyzed 13 patient and system factors that could have contributed to the CLABSI. A similar approach was used by Bundy et al. in a multicenter quality improvement collaborative that included the implementation of a standardized bundle as well as CLABSI survellience. This approach resulted in significant reductions in CLABSI rates among 32 pediatric hematology-oncology centers [60]. In both instances, the use of this RCA approach provided vital data elements that could then be used for system changes and the implementation of improvement strategies.
1. Encourage appropriate use of antimicrobials
2. Initiation of contact precautions for patients with signs and symptoms consistent with CDI, single-patient room preferred
3. Implement a laboratory-based alert system to provide immediate notification about newly diagnosed CDI patients
4. Education of healthcare personnel, environmental service personnel, and hospital administration about CDI, specifically the importance of handwashing with soap and water and the use of personal protective equipment
5. Educate patients and their families about CDI as appropriate, including hand hygiene and the cleaning of cell phones and other personal effects.
6. Cleaning and maintenance of reusable medical devices according to the manufacturer's instructions and institutional policies; do not reuse single-use devices
7. Establish policies and procedures for routine cleaning and disinfection of environmental surfaces in both inpatient and ambulatory care facilities, including placing emphasis on surfaces that are most likely to be contaminated with pathogens and the use of EPA-registered detergents/disinfectants; assess adequacy of cleaning
8. Notify receiving caregivers of CDI within and outside of facility upon transfer
9. Conduct CDI surveillance and analyze and report CDI data
10. Measure compliance with CDC or WHO hand hygiene and contact precautions
When data indicate deviations in bundle performance data, an increase in infections, or other opportunities for improvement, various actions must be taken. A wide variety of causes and contributing factors must be considered, including staff, patient, and family practices, equipment and supply changes, the environment of care, and others. Similar to other areas of patient safety, actions must focus on high leverage changes that provide fundamental and lasting changes in the process of care. Simple actions such as education and policy changes may provide value in some situations, but rarely provide lasting change and improvement. Iterative, ongoing improvements will often be needed to embed lasting change into practice, and leaders must be nimble and responsive to promote changes in practice.
Participation in formal collaborations across children's hospitals focused on reducing HAI has become a core technique. The Quality Transformation Network, managed by the Children's Hospital Association (CHA), unified pediatric hospitals to work together in order to deliver high-quality, reliable, and safe care for pediatric patients [56]. Initial collaborative efforts to prevent HAI in children's hospitals were focused on CLABSI in the pediatric intensive care unit (PICU). The successful PICU work prompted CHA to expand these efforts to inpatient pediatric hematology-oncology units in 2009, and to the ambulatory setting in 2011, by creating the Hematology-Oncology CLABSI Collaborative, later renamed the Childhood Cancer and Blood Disorders Learning Network (CCBDN) [56, 60, 65]. Recently, the CHA collaborative has worked with SPS [56]. SPS now collects data on inpatient CLABSI for pediatric oncology/hematology units, and CCBDN has concentrated efforts on reducing CLABSI in ambulatory patients with cancer and blood disorders, recognizing that the majority of these children and adolescents receive much of their care outside the hospital and that CLABSI occur more than twice as frequently in the ambulatory setting than in hospitalized children in this population [56, 65, 66].
Ultimately, preventing HAIs is a team effort that requires sustained involvement and engagement across the entire healthcare team as well as patients and families. For example, the entire team should routinely discuss the continuing need for intravenous and urinary catheters. In the pediatric hematology-oncology population, however, care may require a central venous catheter for months to years at a time. Further, to reduce line accesses, nurses and physicians will need to work together to bundle lab draws, and nurses, pharmacists, and physicians will need to work together to switch from intravenous to oral therapy. All of this ongoing communication must occur in an environment with a positive patient safety culture that encourages team members and families to speak up to make changes for patient care.
Sustaining the improvements achieved after reducing healthcare-associated infections is necessary to continue to obtain successful outcomes in pediatric hematology-oncology patients, given the high rates of infections in this population and the associated morbidity and mortality [2, 67, 68, 69]. Although sustainability has been recognized as a key practice in quality improvement and safety work, including the reduction of HAI in pediatric hematology-oncology patients, it does not occur automatically [70]. The Institute for Healthcare Improvement refers to sustainability as locking in the progress that groups have made already and continually building upon it [71]. In pediatric hematology-oncology patients, sustaining reductions in HAI implies adoption and long-term implementation of the established evidence-based practices that are known to result in infection rate reductions, such that these become the norm within a group and ideal adherence is accomplished (i.e., strict compliance with the central line care bundle to reduce CLABSI). The goal is to develop a change to reduce pediatric HAI with enduring impact, even after the initiative is no longer the top priority for a group, and it begins to function without additional dedicated resources. Yet, maintaining a positive change long-term is known to have a high rate of failure, and only limited reports exist of sustained healthcare improvements [72].
Some of the factors associated with difficulty achieving sustainable change are not specific to efforts aiming to reduce HAI in pediatric hematology-oncology patients, but certainly apply. These include incorporation of new staff unaware and/or untrained in best practice and the development of new projects that create distraction or shift the focus away from infection reduction, complacency, and the commonality of emergencies and complex cases in this group of patients, which can at times justify the lack of adherence to best practice [73]. Therefore, a specific focus on sustainability is necessary in order to hold on to the gains achieved.
Strategies for sustainability must be incorporated early on and embedded into the process as it occurs, such that it is inseparable from the process of designing, testing, and implementing change. Some of the improvement strategies utilized to achieve reductions in HAI can also lead to sustainability independently, but a formal focus on this aspect through careful planning increases the chances of maintaining improvements. A number of approaches to foster sustainability after change based on high reliability principles have been described in other chapters of this book and elsewhere [71]. Many of these are applicable to preserving the changes after reductions in pediatric hematology-oncology HAI are obtained, but limited evidence exists that is unique to sustainability in this particular area. Rather, efforts have primarily been concentrated on achieving improvements and reducing HAI in this vulnerable population, rather than on upholding gains.
Organizing children's hospitals around the United States into large-scale pediatric collaborative improvement networks has been an overarching principle in successful and sustainable pediatric quality improvement and safety efforts. These efforts have paved the way for additional healthcare improvement and safety initiatives in pediatric hospitals. These, in turn, have led to sustainable reductions in patient harm, including fewer pediatric HAI [47, 49, 54]. The first visible success story in sustainable improvements specific to pediatric cancer and blood disorder patients resulted from the CHA CCBDN effort to reduce inpatient CLABSI in pediatric hematology-oncology patients; this has successfully achieved and maintained an inpatient CLABSI rate reduction of approximately 28% for years [60].
Collaboration has been central in sustaining reductions in CLABSI rates in pediatric hematology-oncology patients and spreading change. Hospitals collaborating in networks are being encouraged to share success stories and helpful tools and strategies in achieving and maintaining reductions in CLABSI rates. In addition, networking provides a platform for spread and expansion. The success of networking and collaboration is based on providing a common forum to work, learn, and improve together [60, 74].
The collaborative success in pediatric hematology-oncology CLABSI reduction highlights a number of strategies that are central in sustaining change within this complex population. These can be summarized into three categories: People, Process, and Place (the three Ps).
Similar to the importance it has in achieving improvement, a strong leadership that is visible and effective is central to sustaining change. The collaborative has provided this at a high level, but individual institutions also require the presence of strong leaders locally in order to maintain the changes achieved. A large majority of successful efforts in reducing CLABSI in pediatric hematology-oncology patients have emphasized the importance of a dedicated team with direct leadership, central to maintaining hospital-wide support even after the goal has been achieved, such that efforts can be continued [60, 68, 75].
One of the main strategies of sustaining a change that is primarily reliant on staff consistently performing all aspects of a bundle, as is as the case with many pediatric HAI prevention efforts, is ensuring formalized ongoing staff education and training of newcomers on best practice. This requires high-quality training of staff, where multidisciplinary teamwork and communication are key to successfully holding on to the gains achieved [73]. Formal competency testing processes are essential. One recommended approach is to have ongoing formal competency testing through fidelity simulation, which has been associated with assuring competency in care delivery of aspects such as central line care [70, 71].
Standardization and spreading of change are both key aspects to sustainability [71]. These aspects were also observed as a result of the large-scale collaboration to reduce CLABSI in pediatric hematology-oncology patients. Participating children's hospitals across the nation were required to continuously report rates of infection and compliance with the central line care bundle [60]. The collaborative reproduced detailed data about CLABSI and bundle compliance rates for participating centers, allowing for transparency, visibility, and the ability to generate benchmarking data facilitating comparison among centers. Furthermore, the process of monitoring and reporting continued even after a reduction in CLABSI rates was observed, thus serving as a main strategy in sustaining gains. Monitoring and reporting of infection rates incentivizes adherence to best practice and, therefore, leads to sustained reductions in rates. Similarly, connecting teams at other hospitals reduces trial and error to find effective solutions. Also central to sustainability is the fact that these initiatives were expected to be long term and were built to persist until goals were achieved and quality improvement was maintained [60, 66, 67].
In pediatric hematology-oncology CLABSI reduction, the collaborative's use of self-audit not only served as a measurement tool but also as a reminder to staff regarding best practices when caring for central lines. This strategy encourages strict compliance with evidence-based practice, standardization, ongoing monitoring of performance, and incorporation into the daily routine, all of which are aspects central to maintaining change [60, 74]. Other strategies that have been used include the development of processes to learn from outstanding scenarios by RCA and identifying local barriers through methodology such as failure modes and effects analysis, a strategy used to prospectively identify areas of risk. One group specifically described the importance of ongoing monitoring of infection rates and the need to have a process in place to respond to unexpected changes in the face of an observed rise in CLABSI rates. Their strategies included preemptively identifying patients with CLABSI-specific risk factors, identification of variables associated with increased CLABSI rates directly from frontline staff, and the evaluation of variables associated with increased micro-system stress [76].
Embedded in every improvement process that is meant to last is the need to promote culture change [71]. In pediatric hematology-oncology, reducing HAI has required both a national and international focus that has helped identify the severity of the problem and concluded that improvements are achievable. The large-scale collaboration that has led to sustainable reductions in pediatric hematology-oncology CLABSI both directly and indirectly contributed to culture change [60, 66]. An emphasis on reducing HAI collectively led to increased awareness of the problem. This key step in developing culture change also indirectly led to increased attention to detail, and both contributed to a focus on safety culture and changes in belief systems [60, 66, 71].
In summary, attitudes toward infectious complications of pediatric hematology-oncology care have evolved over the past decade from the belief that these illnesses were largely inevitable to the understanding that, with diligent adherence to best practices, the incidence of many common infections in pediatric hematology-oncology patients and transplant recipients can be significantly reduced. The efforts of individual institutions are critical to identifying risks for infection in these populations and new strategies for infection prevention and ensuring that the organization itself maintains compliance with standards. Large-scale collaborations have provided forums for testing of new interventions; for disseminating standardized, evidence-based infection prevention methods; and for developing measurement and monitoring processes and benchmarks for improvement. Although still a relatively new effort, the systematic incorporation of quality improvement strategies has already demonstrated great promise in reducing the morbidity and mortality associated with infection in children and adolescents with cancer and improving disease outcomes.
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text:
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subset: commoncrawl


text:
Badger Basket Royal Pavilion Round Doll Crib
Badger Basket Royal Pavilion Round Doll Crib
In Stock
Clicking buy now will open a new window and direct you to this item on target.com. Pricing and availability subject to change
Badger Basket's Royal Pavilion Round Doll Crib with Canopy and Bedding is plush and elegant for all kids and doll collectors who wish for the most graceful doll furniture. Full bedding set includes a skirt, liner, padded mat, and canopy with drapes and tiebacks. Also has wheels for mobility. For children ages three and up and dolls up to 18 inches. Made with metal, plastic, fabric, and MDF. Wipe, spot clean, and hand wash as needed. Overall assembled dimensions: 20 inches in diameter x 33 inches H. Adult assembly required (no tools needed).
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text:
Every governor knows how their role has grown in recent years and how the expectations of them have risen in parallel. However, one critical event in the annual governance calendar that has always been with us is Headteacher Appraisal.
One of my favourite films is "Billy Elliott". I had tears when Julie Walters reads Billy's letter and when his grandma, says "...I could have been a ballet dancer!". As a teacher, gran's lack of opportunity played heavily on me. I asked myself; "Will any of my pupils ever have such sad regrets in their later lives?"
Internet provision is now essential to schools...find out all you need to know about choosing a provider
You may have noticed that current Ofsted inspection frameworks and criteria for both full inspections (Section 5) and short inspections (Section 8) remain the same...find out more.


text:
Board of Zoning Appeals
The Board of Zoning Appeals (BZA) hears requests for variances, special exceptions and appeals. The BZA holds monthly public hearings in the City Council Chambers at 7:00 p.m. on the 2nd floor of City Hall.
- Meetings and Agendas
- 2018 Filing Deadlines and Hearing Schedule ( Updated 10.15.2018)
- 2019 Filing Deadlines and Hearing Schedule
- 2020 Filing Deadlines and Hearing Schedule
- FY 2019 Board of Zoning Appeals Annual Report
Special Use Permits
Uses listed in the Zoning Ordinance as Special Uses require either an administrative or public hearing Special Use Permit (SUP) before they can be established. Forms are available below to apply for SUP approval.
- Meetings and Agendas
- Planning Commission Hearing Schedule and Filing Deadlines
- Information on the Special Use Permit Process
Zoning Initiatives
- Initiatives
- Small Business Zoning
- Accessory Dwelling Units (Information forthcoming)
- Inclusionary Zoning (Information forthcoming)
- Resources
- Zoning Ordinance
- City Charter and Code
- King Street Outdoor Design Guidelines
- Multifamily Parking Standards for Development Projects
- Small Cell Wireless Facilities
Contact Us
Department of Planning and Zoning
Land Use Services Division
301 King Street, Suite 2100
Alexandria, Virginia 22314
Phone: 703.746.4666
Office hours: Monday - Friday, 8:00am - 5:00pm


text:
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Tag Archives: tenryuji temple
Traveling Japan: Arashiyama's Tenryu-ji Temple
We had come to this area primarily for the Arashiyama Bamboo Forest, but we found so much more than we had expected. One of the things about the city of Kyoto is that there's a UNESCO World Heritage Site around … Continue reading
Posted in Religion, Travel Tagged buddhism, Japan, kyoto, rinzia, tenryuji temple, zen, zen buddhism Leave a comment


text:
Using your hosts file to kill social media noise
Lately social media has felt like an unending river of rage, angst, and bad news. It's a sort of textual noise. This month, I decided to kill the noise, and take a much-needed social media break.
That doesn't necessarily mean spending less time looking at screens — I like you, work, socialize, stay informed on the internet. But it does mean shifting my attention away from my favorite timesuck: Twitter. I've enlisted the help of my hosts file to help me break my habit.
Most operating systems have a hosts file. OS X users (and users of most *nix systems), can find theirs at
/etc/hosts. You can edit it manually, but you'll probably have to use
sudo to do it. Its contents will look something like this:
127.0.0.1 localhost
255.255.255.255 broadcasthost
::1 localhost
Roughly what this does is redirect requests for
http://localhost to
127.0.0.1 is a special IP address that represents the requesting machine. In other words, visiting
localhost in your browser will direct your request back to your computer. Assuming that you aren't running a local web server, you should see an error message.
We can take advantage of this routing to block access to our favorite timewasting sites. Decide which host names you want to block, and direct them to
127.0.0.1. In my case, that's both twitter.com and api.twitter.com (so I can't use the TweetDeck or Twitter apps either).
127.0.0.1 localhost
255.255.255.255 broadcasthost
::1 localhost
# Block my access to timesucks.
127.0.0.1 twitter.com
127.0.0.1 api.twitter.com
Any time I attempt to visit twitter.com from my laptop, I instead see the Chrome error page. Should I decide to return to Twitter, I can delete those lines or prepend them with a
# so they'll be ignored.


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"There is more to life than work . . ."
I am the proud co- founder of Womenreignite
I like to show people around the world that even a school drop-out, a homeless child, and an unwanted immigrant can get to the "top".
I have had many struggles, and as a result, I have written and co-written more than 14 books on all the mistakes, failures and obstacles I have had throughout my life. I was born in Morocco, grew up in Denmark. My pain transformed into my path in 2007 when I was fired while I was pregnant.
It was the most challenging moment in my life. I was a mom to be and the breadwinner of the family, and I've just been fired from my job as a global sales director. It was at that moment that I decided never again to be in a position where anyone could fire me. That same year, I decided to start my own consulting company. I had no idea what to do, but I needed to make a living. All I had was my skills in sales, sales training, strategic sales/strategic partnership, supply-chain management and strategic networking.Those are my "hardcore" skills and talents, and it was easy for me to teach others. So, I decided to start training others. That was the beginning of my consulting company, which led me to become a global keynote speaker, life design coach and author.
However, if it weren't for my strategic networking skills and the ability and courage to speak out on topics that I am passionate about, I would not have been able to succeed. As a result, today I have done about 200 public talks/year around the world, in more than 33 countries, with some of the biggest companies in the world, such as Volvo, Siemens and Maersk.
Adversity made me stronger. Throughout my upbringing, I developed some qualities and survival techniques that still play an essential part in my drive for success today. I was separated from my parents when I was only 13 years old (in Denmark), I was kicked out of school in 7th grade, and went through the foster-care system. However, I still managed to succeed and have been recognized with various awards.
My adversity and struggles have become important motivators for me. I cannot change my childhood, but I can appreciate that it is over. What's important is not where you come from, but where you are going. Having a great career and personal life are all about having the courage and the ability to seize the opportunities that you run into and to have a great method.
I believe that people can decide to become successful and reach essential goals through hard work and perseverance. The foundation for my leadership, my values, my focus, and my sense of responsibility can be tracked all the way back to my challenging childhood, but my days of hardship have been transformed into something very positive. I have shared those thoughts in many podcasts and books available in english. I also wrote about this journey and shared my leanings in the e-book "Ignite your Career" and it was downloaded in more than 300.000 copies. Buy it here
Against all odds I received an E-MBA from Copenhagen Business School in 2007 and have received further education and executive training from a number of institutions, including Yale University, Harvard University's Kennedy School of Government, Stanford University, UC Berkeley, INCAE Business School and ISB India. I now teach online and at leading business schools around the world in "life design."
I support many organisations and charities, including UN Women Advisory Group (Denmark); SAC World Economic Forum, YGL, Gender equality (Geneva); The School Challenge Team (world wide), The Global Teacher Prize and many more – read more here
Today I get to work in many countries and I work with some of the smartest people on earth. I dedicated my own life to improving the lives of others. I am a life coach and offer 1:1 sessions online. I make people brave, shine, bold and I help them to unleash their enormous potential and find their talents and passions. I own 3 "online paid membership platforms- and member communities". One of them being the biggest online life design community in Scandinavia with participants from over 42 countries.
In the USA I teach people online "how to design their lives". For more inspiration look at Womenreignite
You can book me via my speaking agent CraigS[at[bigspeak[dot]com
I advise major companies on topics such as customer and sales loyalty, strategic relationships with stakeholders, change management, employee motivation and the future of business. You can ask me about my cases and results at sg[at]soulaima[dot]dk
I am still married to my loving husband for 24 years, a mom to our two kids age 9 and 11.
Avoiding adversity is impossible. What is important is how you tackle adversity. Do you give up, or does it make you stronger?
Today I reside in Palo Alto, California, where I continue to advise American leaders, entrepreneurs and companies in areas such as strategy, management and leadership.
If you want to follow my work feel free to read my weekly FORBES
After 14 years in Denmark we decided in 2016 to move to USA first to Texas and now California, Palo Alto. It is healthy to move to other countries once in a while. I have lived in Luxembourg, Switzerland and Norway and find that these moves boost my creativity, network and cultural understanding.
Naturally my family, being the proud mom of two. I am passionate about traveling, art and sport. I have always been very active in sports with passion for extreme disciplines. I was one of the finalists in the 1995 Miss Fitness Denmark competition, and I have participated in a couple of "adventure extreme races," which are twenty-four-hour orienteering races with a multitude of athletic challenges.


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Federal Tax From 941 Selection Not Showing
Adding a new stream. Have not received any replies to my earlier post. I'm setting up US Payroll for the first time. I'm at the Federal Taxes screen but there is no drop down to select Form 941. I can't finish the set up process. Need help.
7 Replies Only show the Best and Official Replies
Merged: Setting up payroll for first time and can't get past Federal taxes screen
I'm setting up US Payroll for the first time. I've set up the organization and employees but can't get past the Federal taxes screen and set up payroll tax info and then Accounting info. Help!
I'm setting up US Payroll for the first time. I've set up the organization and employees but can't get past the Federal taxes screen and set up payroll tax info and then Accounting info. Help!
Heya Don! Apologies we hadn't come back to you on this one. Best to reach out directly to our Support team about this so they can take a look into your organization and see what's causing this. Make sure to refer to this thread when you get in touch!
Thank you Brittany. I have contacted Xero Support and was told they would call me but that hasn't happened yet. I will try again. I need to get this resolved asap or I'll have to find another payroll option.
Heya just looping back here as I can see my US colleagues have given you a call here. Do let them know if you need any more help :)
I am having the same problem and have reached out to support. I haven't yet heard but I need to run payroll tomorrow. Was there an easy solution to this?
I had to have Xero Payroll Support put me on the old version of Xero Payroll. Did you get through to Payroll Support? Once I got a hold of them they were very responsive and helpful. You first have to go through the general support email and then they will forward to payroll support. Keep replying to the email and they should get back to you hopefully first thing in the morning. After the payroll people respond they will walk you through it and quickly. Good luck. Don
Wonderful to know, Dan. Thank you. I'll keep replying to the payroll support and hopefully we'll get this resolved in the morning. I appreciate your reply and help.


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Born in Kingston, Jamaica,
Winston Fraser - aka JJ Appleby - moved to England.
There he was part of the successful band,
The Equators, who toured the UK, Spain, and even went to New Zealand.
He's got a folksy, gospel sound, a unique Reggae twist, love songs, and a positive message.


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The family of a man killed in a motorcycle-and-car crash last year have filed a wrongful death suit against a Channahon man. George Weikum, 58, was northbound on Route 59 in Plainfield on October 8, 2011. Chanahon resident David Deitrich was heading southbound when he lost control of his 2005 Ford Ranger Pick-Up truck. It [….]
An accident on Route 126 near Plainfield has left one man dead and sent another driver to the hospital. Robert James, of Yorkville, was driving his 2007 Mercury in the eastbound lane of Rt. 126 on September 10th. Just before 6:00 a.m., the 63-year-old James lost control of his car and went into the westbound [….]
A crash over the weekend on the Kennedy Expressway in Chicago resulted in the death of a passenger and the driver charged with a DUI. Pavlo Lulak, 24, was traveling in the northbound lanes of the Kennedy Expressway in his Mitsubishi Lancer when he lost control of the vehicle near Armitage Avenue around 4:20 a.m. [….]
Two men lost their lives in a single car accident that occurred just after midnight on Sunday near the Iroquois County Fairgrounds in Crescent City. A third man was hospitalized with non-life threatening injuries. Iroquois County Coroner Bill Cheatum determined that Curtis Riston II, of Watseka, was driving east on 2000N Road in Iroquois County [….]


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By PAUL LASTER, February 2020
Returning for its 66th edition, The Winter Show offers a highly vetted selection of art, antiques and design presented by 72 international exhibitors at New York's Park Avenue Armory through February 2, 2020.
Perusing the fair and learning from dealers, we've chosen 25 works that we would add interest to any collection of fine and decorative arts—ranging from paintings by Arthur Dive and Ida Ten Eyck O'Keeffe (Georgia O'Keeffe's younger sister) and Harry Bertoia, Fritz Klitsch and Emily Young's sculptures to drawings by Andy Warhol and Axel Salto and Ugo Zaccagnini's ceramics.
Scroll through to see more images of our favorite pieces at the fair. WM
Paul Laster is a writer, editor, independent curator, artist and lecturer. He is a New York desk editor at ArtAsiaPacific and a contributing editor at Whitehot and artBahrain. He was the founding editor of Artkrush.com and Artspace.com and art editor of Flavorpill.com and Russell Simmons's OneWorld Magazine; started TheDailyBeast.com's art section; and worked as a photojournalist for Artnet.com and Art in America. He is a frequent contributor to Time Out New York, New York Observer, Modern Painters, ArtPulse and ArtInfo.com.view all articles from this author


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Evidence In Motion's Specialty Certification in Stroke Recovery is a post-professional clinical and didactic program designed to translate evidence into practice and provide PTs and OTs with the tools to provide best practice management in persons following stroke. This evidence-based curriculum will guide participants through the full spectrum of stroke rehabilitation, from neuroanatomy and pathology to examination and treatment, with the ultimate goal of facilitating recovery of function and improved reported quality of life.
Choose two courses for your Plan of Study.


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High Country- HD Surround Vision w/ 2 Trailer Camera Provisions, Navigation, Head-up Display, Bed View Camera, Leather/ Heated/ Ventilated Front Seats, Heated 2nd Row, Leather Wrapped/ Heated Steering Wheel, Lane Keep Assist, Wireless Charging, Bose Speaker System,
Wilson-Niblett Motors has been proud to serve York Region for almost six decades! We want to thank you, our loyal customers, for making us the success we are today! If you're part of our "family", you already know about our commitment to outstanding customer service and satisfaction and to being your dealership of choice in the region. Want to shop from the comfort of your own home? We offer our vehicle buying experience online including personalized virtual walk-arounds, test drives at home and at-home deliveries. Call 1-866-508-9030 and one of our knowledgeable product specialists will be happy to assist you or visit our showroom at 10675 Yonge Street in Richmond Hill.
Wilson Niblett price is a cash price and is inclusive of General Motors cash credits of $7750 and a Wilson Niblett Cash credit of $2,360 . Pricing may not be compatible with finance and lease offers. All prices are plus applicable taxes and licensing. Offers valid until March 31, 2020


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Warnambool Athletics Club are a social club, providing varied and scenic runs around the region. People of all ages are welcome to run in this charity event.
Due to current advice on public gatherings, please contact the host of this event to confirm it is proceeding as planned.
- Disabled access available, contact operator for details.
Contact details
Phone: 0405 759 012
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6 kilometre Handicap - Thunder Point
09:00 - 12:00
, Warrnambool, VIC 3280 View map
Phone: 0405 759 012
Email: firstname.lastname@example.com
Website: Visit Website


text: Honey Grove TSCRA Special Rangers Recover $105,000 in Stolen Property By Press Release • Sep 17, 2019 BONHAM, Texas — A suspect was arrested, and more than $105,000 in stolen property was recovered after an investigation by Texas and Southwestern Cattle Raisers Association (TSCRA) Special Ranger Troy McKinney and the Fannin County Sheriff's Office. How The Load Trail Raid Affected Honey Grove Schools By Stella M. Chávez • Mar 25, 2019 Stella M. Chavez / KERA The day of the raid still haunts principal Tammy Mariani. On August 28, agents from U.S. Immigration and Customs Enforcement, or ICE, raided a Northeast Texas factory that makes vehicle trailers. In the nearby Honey Grove Independent School District, nearly two dozen children have parents who were arrested and detained. May elections: Bonham to elect new council members By Amanda Heflin • Apr 9, 2015 provided image The Fannin County May 2015 election has one uncontested mayoral election in Bonham. Bonham Ward 1: John Burnett (Uncontested) Ward 5: Kevin Hayes, Lewis Faith At-Large:Chantal Carey, Robert Thomas, Tony Rodriguez Mayor: Roy Floyd (uncontested) Honey Grove Alderman at-large: Billy Bob Stephens, Leigh Dixon, Done Morrison Ector City Council: Kenneth Rhudy, Jimmy Dixon, Jerry (Sweet Tea) Newell, Dale Holt When the North Sulphur was a swamp By Mark Haslett • Jul 8, 2013 Mark Haslett / KETR The plan to build Lake Ralph Hall in southern Fannin County is mainly a response to the region's water needs. But there's an environmental aspect with its roots in the area's natural history. After fire, church community endures By Mark Haslett • Feb 14, 2013 Mark Haslett In the Fannin County town of Honey Grove, one Ash Wednesday service was different this year. Water Improvements Coming for Emory, Honey Grove By Brad Kellar • Oct 18, 2012 AUSTIN - The Texas Water Development Board more has approved more than $1.7 million in water infrastructure improvements for parts of Rains and Fannin counties.


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This This Bianco SS is offered without its model year noted, and unfortunately it's not easy to come by detailed info regarding these Brazlian-built, fiberglass-bodied cars. BaT featured an earlier, VW-powered example early last year, though apparently the seller of that car was incorrect in stating that production ended in 1980 after just 80 or so were made–this one clearly looks later (despite sharing a similar profile) and is said to be one of around 200. Like the earlier Bianco, this one looks like it could be quite a pretty car, though unfortunately photos are very poor quality. The car's Porsche 911 SC swap definitely caught our attention however, and the seller adds that it was rebuilt around five years and 2k kilometers ago. Overall a very intriguing car, and one which we'd love to see some better photos of. Find it here on eBay in Hanau, Germany with a 56,500 euro (~$67,600 USD today) starting bid and no further reserve.
Dark blue suits this shape nicely, though a few random closeups suggest that paint finish may be of a so-so quality. Porsche 944 S2 wheels look cool however, and though heavily shadowed, it's clear that this car shares a lot with the earlier Bianco linked above. Doors appear to be conventionally hinged.
The rear is very similar to that of the earlier Bianco as well, with a modified version of its six-taillight rear end and a ventilated, stepped up engine lid–note the grille-inset Bianco SS badge and big, custom-made stainless exhaust can between fairly large diameter pipes on either side.
Here's a look inside the cabin. Note the 911-sourced gauges and WEVO shifter, as well as the dual fans–windows look to roll down but it seems safe to assume that there's no A/C and that cabin temps might get pretty hot.
Here's the SC mill. According to the seller it was rebuilt around five years and 2,000 kilometers ago, with work including new valve guides and seals as well as retrofitted hydraulic chain tensioners.
The bay is definitely a bit of a mess, but better lighting does finally seem to show the car's color more accurately–we imagine it's somewhere between this bright shade and the very dark, almost navy shade seen elsewhere.
Did you mean to enter this number as a bid? If so please use the bidding box above.


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- The National Small Industries Corporation Limited(NSIC) has signed an MoU with Ministry of Micro, Small and Medium Enterprises for the year 2019-20.
- The MoU envisages provision of enhanced services by NSIC under its marketing, financial, technology and other support services schemes for MSMEs in the country.
- Under the scheme of National SC-ST Hub,implemented by NSIC on behalf of the Ministry of MSME, it will continue to provide assistance to SC/ST entrepreneurs with the overall objectives to increase their participation in public procurement.
- The NSIC also plans to enhance its activities in the areas of imparting entrepreneurship and skill development training to MSME by targeting 45 % growth in the number of trainees.
- NSIC is a Government of India Enterprise under the Mini-Ratna Category.It was established in 1955.NSIC has been working to promote, aid and foster the growth of micro, small and medium enterprises in the country.It works under Ministry of Micro, Small and Medium Enterprises (MSME).
NSIC signs MOU with Ministry of MSME
6 min read


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Review: DUB Wheel Cleaner
DUB Wheel Cleaner
DUB Wheel Cleaner is developed by Meguiar's and is a great product at a great price. It's available locally as well as online and has an MSRP of $8.99. It features color-changing chemicals that turn from a yellow-green hue to a red-purple color when in contact with iron contaminants. This color-changing action helps you know that the cleaner is working to get that pesky brake dust off your wheels.
Safe on All Wheels, Brakes, and Suspension Components
DUB Wheel Cleaner is safe to use on most finishes including chrome, painted, machined, or any factory wheel finishes. To be safe, we recommend testing the product inconspicuous location to confirm that the cleaner is safe on your wheels.
DUB claims that this product has a Piña Caliente fragrance, and although it does smell sweeter than other wheel cleaners, it's nothing to write home about. In fact, we recommend using this product in an open environment with good airflow.
- A lot of manufactures claim that their wheel cleaner does not need agitation to work. We don't agree with this statement, and agitation is recommended to get the nooks and crannies clean.
- If you are sensitive to chemical smells, we recommend using a respirator.
- We recommend using Nitrile Gloves when using any chemicals.
A picture is worth a 1000 words and the results show it. We achieved these results with 3 tools.
Where to Purchase:
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