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Purpose: To investigate the possibility of constructing a multiprofessional cross-cultural measure of functioning after stroke across categories of the International Classification of Functioning, Disability and Health (ICF). Method: Data on 757 stroke survivors from China, Germany, Italy, and Sweden, including ratings of 15 categories from the Brief ICF Core Set for stroke, were analyzed using the Rasch model. Unidimensionality, reliability, fit of the ICF categories to the model, ordering of response options of the ICF qualifier, and presence of differential item functioning (DIF) were studied. Results: Of the 15 ICF categories, response options for 7 categories were collapsed, 5 categories were deleted due to misfit, and 4 ICF categories showed DIF for country and were accordingly split into country-specific categories. The proposed final clinical measure consists of 20 ICF categories (6 categories were country-common) with an overall fit statistic of χ2180 = 184.87, P = .386, and a person separation index of r = 0.72, which indicates good reliability. Based on an individual's functioning after stroke, the ratings across the different ICF categories can be summed on an interval scale ranging from 0 to 100. Conclusion: A construction of a cross-cultural clinical measure after stroke based on ICF categories across body functions, structures, and activities and participation was possible. With this kind of clinical measure, stroke survivors' functional levels can be compared even across countries. Despite the promising results, further studies are necessary to develop definitive measures based on ICF categories.
Background. In line with patient-centered health care, it is necessary to understand patients' perceptions of health. How stroke survivors perceive their health at different time points after stroke and which factors are associated with these feelings provide important information about relevant rehabilitation targets. Objective. This study aimed to identify the independent factors of health-related quality of life (HRQoL) from a biopsychosocial perspective using the methods of multivariate regression at 3 different time points poststroke. Methods. Included in the study were 99 patients from stroke units with diagnosed first-ever stroke. At admission and at 6 weeks, 3 months, and 1 year poststroke, HRQoL was assessed using the EuroQoL-5D Visual Analogue Scale (EQ-5D VAS). Consequences in Body Functions and Activities and Participation, and Environmental Factors were documented using 155 categories of the International Classification of Functioning, Disability and Health (ICF) Core Set for Stroke. Results. For a period of 1 year, problems with recreation and leisure, personality functions, energy and drive functions, and gait pattern functions were repeatedly associated with worse HRQoL. Whereas Body Functions and Activities and Participation explained more than three-fourths of the variances of HRQoL at 6 weeks and 3 months (R 2 = 0.80-0.93), the variation at 1 year was best explained by either Body Functions or Environmental Factors (R 2 = 0.51). Conclusions. The results indicate the importance of Body Functions and Activities and Participation (mainly personality functions and recreation and leisure) on HRQoL within 3 months poststroke, but increased impact of Environmental Factors on HRQoL at 1 year.
Assessing the competence of registered radiographers' clinical work is of great importance because of the recent change in nursing focus and rapid technological development. Self-assessment assists radiographers to validate and improve clinical practice by identifying their strengths as well as areas that may need to be developed. The aim of the study was to develop and psychometrically test a specially designed instrument, the Radiographers Competence Scale (RCS). A cross sectional survey was conducted comprising 406 randomly selected radiographers all over Sweden. The study consisted of two phases; the development of the instrument and evaluation of its psychometric properties. The first phase included three steps: 1) construction of the RCS; 2) pilot testing of face and content validity; and 3) creation of a web-based 54-item questionnaire for testing the instrument. The second phase comprised psychometric evaluation of construct validity, internal consistency reliability and item reduction. The analysis reduced the initial 54 items of the RCS to 28 items. A logical two-factor solution was identified explaining 53.8% of the total variance. The first factor labelled "Nurse initiated care" explained 31.7% of the total variance. Factor 2 labelled "Technical and radiographic processes" explained 22.1% of the total variance. The scale had good internal consistency reliability, with a Cronbach's alpha of 0.87. The RCS is a short, easy to administer scale for capturing radiographers' competence levels and the frequency of using their competence. The scale was found to be valid and reliable. The self-assessment RCS can be used in management, patient safety and quality improvement to enhance the radiographic process.
OBJECTIVES: To describe radiographers' self-assessed level and use of competencies as well as how sociodemographic and situational factors are associated with these competencies, particularly related to work experience.
METHODS: A cross-sectional design was employed. Radiographers (n = 406) completed the self-administered 28-item questionnaire encompassing two dimensions: 'Nurse-initiated care' and 'Technical and radiographic processes'. The level of competencies was rated on a 10-point scale and the frequency of use on a 6-point scale.
RESULTS: Most competencies received high ratings both in terms of level and frequency of use. In 'Nurse-initiated care' the competency 'Adequately informing the patient' was rated the highest, while 'Identifying and encountering the patient in a state of shock' and 'Participating in quality improvement regarding patient safety and care' received the lowest ratings. In 'Technical and radiographic processes' the highest rated competencies were 'Adapting the examination to the patient's prerequisites and needs' and 'Producing accurate and correct images'. The lowest frequency of use was 'Preliminary assessment of images'.
CONCLUSION: The main findings underline the radiographers' high competency in both 'Nurse-initiated care' and 'Technical and radiographic processes'. The lower rated competencies emphasise the importance of continuous professional education and quality improvement.
• Assessing radiographers' clinical competencies is fundamental for ensuring professional standards.
• Most competencies received high ratings both in the nursing and in the radiographic dimensions.
• The highest rated competencies focussed on information and adaptability to the patients needs.
• The lowest rated competencies focussed on encountering the patient in shock and image assessments.
• Age, years in present position and work place only explained a relatively small part of competency.
Patients must be able to feel as much trust for caregivers and the healthcare system at the healthcare centre as at the emergency department. The aim of this study is to explain and understand the phenomenon of trust in the early chain of healthcare, when a patient has called an ambulance for a non-urgent condition and been referred to the healthcare centre.
A lifeworld hermeneutic approach from the perspective of caring science was used. Ten patients participated: seven female and three male. The setting is the early chain of healthcare in south-western Sweden.
The findings show that the phenomenon of trust does not automatically involve medical care. However, attention to the patient's lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the "voice of the lifeworld" enables the patient to feel trust.
Trust in the early chain of healthcare entails caregivers' ability to pay attention to both medical and existential issues in compliance with the patient's information and questions. Thus, the patient must be invited to participate in assessments and decisions concerning his or her own healthcare, in a credible manner and using everyday language.
Attityder till ätandet
I våra ansträngningar med att utveckla och förbättra det arbete som utförs inom vård och omsorg försöker vi använda handlingar som bedöms vara evidensbaserade. Ofta vet vi, eller i alla fall tror vi oss veta, vilka metoder, åtgärder och program som idag anses vara det mest riktiga. Något helt annat är vad som faktiskt används och görs i det kliniska arbetet. Att fånga vad som görs i syfte att utvärdera resultatet av given vård och omsorg innebär stora utmaningar. Vi kan använda kvantitativa mått på vårdkvalitet som tex. viktutveckling, underbenets omkrets och antal patienter/vårdtagare som fått sitt beräknade energibehov tillgodosett under en vårdperiod. Dessa mått är bra men grova och fångar eventuellt redan uppkomna kvalitetsbrister. Ett annat sätt är att observera vad som görs i olika vårdsituationer men detta arbetssätt medför en hel del svårigheter. Det är etiskt problematiskt, kostsamt men framförallt kommer observationen i sig att påverka vårdsituationen så mycket att det som görs inte blir representativt för praxis. Ett tredje sätt är att studera "personalens tänkta handling". Metoden för detta är attitydstudier. En attityd anses bestå av tre komponenter; en känslodel, en kunskapsdel och en tänkt handling. Studier visar att en tänkt handling ofta leder till en utförd handling. Genom att formulera påståenden kring ett viktigt fenomen inom vård och omsorg kan olika personalgruppers attityder till viktiga områden fångas. Resultatet kan därigenom identifiera områden som personalgrupper uppvisar negativa attityder till. Med vetskapen om att negativa attityder har ett starkt samband med vilka handlingar som görs kan utbildningsinsatser sättas in. Ett annat användningsområdet är att före och efter ett förändringsarbete som tex. inkluderar utbildning och ändrat arbetssätt fånga hur eventuellt attityderna till ett viktigt område ändrades.
Staff Attitudes to Nutritional Nursing Care Geriatric scale (SANN-G skalan) är ett instrument som fångar attityderna hos personal som arbetar med äldre vård- och omsorgsbehövande med avgränsning till "faktorer som är viktiga för ätandet och näringstillståndet". Skalan är ett formulär av Likert-typ och består av 18 påståenden. Den svaranden tar ställning till fem svarsalternativ; håller helt och hållet med, håller delvis med, tveksam, tar delvis avstånd och tar helt och hållet avstånd. Påståendena har sitt ursprung från en litteraturgenomgång där antalet påståenden initialt var 63. Efter olika statistiska analyser där bl.a. påståendenas diskrimineringsförmåga testats har antalet reducerats. Vid faktoranalys framkom att påståendena täcker fem delområden; normer, vanor, bedömningar, åtgärder och individualisering. Den första versionen av skalan har använts för att undersöka om attityderna förändras efter utbildning av undersköterskor och sjuksköterskor (n= 151) inom kommunal äldreomsorg och att rutinerna kring måltiderna ändrades. Personalen som fått utbildning och ändrat sitt arbetssätt uppvisade signifikant mer positiva attityder till området individualisering jämfört med kontrollgruppen men inom övriga områden hade ingen förändring skett. SANN-G skalan har använts för att undersöka om det fanns skillnader i attityderna mellan olika personalgrupper. Åttio sjuksköterskor och 104 undersköterskor med tjänst inom medicinsk eller geriatrisk klinik vid två sjukhus ingick. Resultatet visar att sjuksköterskorna hade signifikant mer positiva attityder jämfört med undersköterskorna. För hela gruppen uppvisade 53% av personalen positiva attityder. Studierna indikerar att attityderna förmodligen har sin grund i normer och vårdkulturer, "det sitter i väggarna", och utgör en stor utmaning att förändra.
Objective:A positive attitude is assumed to be important in nursing staff's help and support of elderly people during meals. As there is no specific tool for measuring staff's attitudes regarding important issues within eating and nutrition, the SANN (Staff Attitudes to Nutritional Nursing Care) scale was developed. The scale was developed and tested in nursing staff working at resident homes, and the number of items was reduced from 63 to 19 with five underlying factors. The aim of this study was to describe how the SANN scale was adapted and tested in nursing staff working in different types of elderly care. Design: The raw 63-item version went through minor changes, and one unclear worded item was excluded. The changed raw 62-item version was answered by 188 nursing staff working at six hospital care clinics and 64 staff working at one resident home.
Results:The analysis reduced the 62 items to 18, and the adapted scale was named the SANN-G scale, G standing for "geriatric care". A rotated factor analysis gave a five-factor solution, explaining 54% of the variance. The scale achieved good internal reliability, with a Cronbach's alpha of 0.83. Fourteen items fulfilled inclusion criteria in both the SANN and the SANN-G scales.
Conclusion:The SANN-G scale is practicable for use in staff working in different types of elderly care. It can be used to explore existing attitudes and identify areas with a low degree of prevailing positive attitudes as well as to evaluate whether and how attitudes change after nutritional education and intervention.
Objectives: Negative attitudes in society toward working in eldercare constitute a challenge to educators and care providers. The purpose of this study was to explore, describe, and compare the attitudes of different professional groups toward factors that are important for the well-being of older adults.
Methods: A randomized sample of 210 respondents that included registered nurses (RNs), registered occupational therapists (OTRs), personal benefit advisors (PBAs), and home help assistants (HHAs) was collected from social service agencies in 10 Swedish municipalities. A scale was developed in a six-step process to measure attitudes toward factors influencing elder wellbeing, and the final 22-item Likert-type scale was called the "Staff Attitudes toward the Well-being of Older Adults" scale.
Results: Thirty-three percent of staff responded with positive attitudes <toward working with elders>, and the remaining were uncertain or negative. The attitudes of RNs, OTRs, and PBAs were significantly more positive than those of HHAs.
Discussion: The scale is practical for use in different professional groups with the aim of exploring existing attitudes, identifying areas with a low degree of prevailing positive attitudes and differences between groups, and evaluating whether attitudes change after staff training.
11th INTERNATIONAL NURSING RESEARCH CONFERENCE
Madrid, November 14th – 16th 2007
PAPER TITLE: A Nutritional Nursing Care Model introduced to Elderly People admitted to Resident Homes
AUTHOR/S: Lennart Christensson, RN, PhD and Kerstin Wikby, RN PhD.
WORK PLACE: School of Health Sciences, Department of Nursing, Jönköping University.
ADDRESS: Box 1026, 551 11 Jönköping, Sweden
E-MAIL: email@example.com
Malnutrition among the elderly is a multidimensional concept, involving medical, psychological and social factors. Fulfilling nutritional requirements in residents with eating problems is often a challenge for both the person in need of help and for the care giver.
Objectives: The primary objective of this study was to determine whether educating care givers have effects on the improvement of nutritional status among elderly people, newly admitted to resident homes.
Methods: The study was based on an earlier single-case study, where a model for nutritional nursing care was developed. In this study a pre-post test design was used, including 62 residents in the experimental (20 men, 42 women) and 53 in the control group (14 men, 39 women). The residents were newly admitted to a resident home and were consecutively included in the study. Mean age was 85 years. At admission and after four months protein-energy malnutrition (PEM) was assessed, using a combination of anthropometry (weight index, arm muscle circumference and triceps skinfold thickness) and biochemical measurements (serum protein and transthyretin). Functional capacity and overall cognitive function were also assessed. In the experimental unit, a nutritional nursing care model was introduced and the staff received education about nutritional needs, and how to individualise nutritional care.
Findings: Twenty residents in the experimental and 17 in the control group were assessed as PEM at admission. After four months the number of residents assessed as PEM decreased to seven in the experimental (p=0.004), and to ten in the control group (p=0.1). Motor activity (p=0.006) and cognitive function (p=0.02) increased in the experimental group, while motor activity decreased in the control group (p=0.02). The care givers in the experimental group estimated the extra work, caused by the changed way of work during the meals, to 11/2 minute per resident and day.
Discussion: Individualised actions directed towards PEM residents are in line with the recommendation by the European Society of Parenteral and Enteral Nutrition (ESPEN) and with the Swedish goals of nursing action. Nursing actions towards nutritional problems include more than merely to offer a standard care plan, such as giving oral supplementation. As the nutritional problems often demands a deeper analysis of the underlying causes, individualized nursing actions may be a more optimal approach. This study shows that implementing an individualised nutritional programme increase nutritional status, motor activity and cognitive function in PEM residents. The nutritional care programme was implemented with a minimum of extra work.
Aims and objectives: To identify and describe nursing actions performed by nurses that create a sense of good nursing care in patients with wet age-related macular degeneration.
Background: People who suffer from wet age-related macular degeneration risk central vision loss. Treatment with antivascular endothelial growth factor is the only available option at present that preserves vision and no definitive cure currently exists. Patients feel that they are compelled to accept this treatment because they might otherwise become blind.
Design: An explorative and descriptive design based on the critical incident technique was used.
Method: Interviews with 16 Swedish patients who all had received intravitreal treatment for wet age-related macular degeneration.
Results: Two main areas of good nursing care were identified: 'Being perceived as an individual' and 'Being empowered'. The first area was divided into two categories: being respectful and being engaged. Being respectful was observed when nurses had a benevolent attitude towards their patients and answered questions kindly and politely. Patients saw themselves as individuals when nurses were available for conversation and focused on them. The second area was divided into two categories: encouraging participation and creating confidence. Encouraging participation refers to when nurses provided information continuously. Nurses instilled confidence and trust in their patients by keeping promises and by being honest.
Conclusions: A respectful interaction between patients and caregivers is necessary for patients to obtain beneficial health care.
Relevance to clinical practice: Patient interviews revealed important information about nursing actions that created a sense of good nursing care in patients with wet age-related macular degeneration. Nurses acknowledged people as individuals and created trust by building partnerships and sharing decision-making. To address each patient's concerns, nurses need to prioritise each patient's narrative and participation by documenting agreements in their medical record.
Evidence supports the recommendation for follow-up session(s) for patients after discharge from an intensive care unit (ICU). The aim of these follow-up sessions is to allow patients to express and discuss their experiences and problems following their time in an ICU. To optimise the knowledge gained from the follow-up session experience, it is necessary to describe how patients experience these sessions. The aim of this study was to describe how ICU-patients, experience a follow-up session.
This study adopted a qualitative design utilising semi-structured interviews, and which examined the experiences of seven men and five women. Qualitative content analysis was utilised.
The participants stated that the information gained from these sessions, which had previously seemed unclear to some of them, was, on the whole, now clarified and confirmed. A discernible difference was found between participants who were cared for on a general ward and those who were cared for on a rehabilitation ward and also were offered a meeting with a counsellor, following discharge their from the ICU. The findings also indicated that participants who were not offered psychosocial support showed a greater need for a follow-up session.
This study has highlighted the need for increasing collaboration between intensive care staff and staff in other units to provide support to this patient group in order to reduce their suffering post intensive care experience.
Background: As difficulties in performing daily activities occur among persons with dementia, their spouses are also affected. This is also true for mealtimes, yet there is a lack of knowledge and research into how couples manage this situation at home. Objective: The aim of the study was to explore and describe spouses' experiences of mealtimes in couples in which one partner has dementia. Design, Setting and Participants: Ten spouses were interviewed in their home in respect to their experiences regarding mealtimes when living with a partner diagnosed with dementia. To identify themes across the data set, thematic analysis was conducted. Results: One major theme, Recognizing and managing the range of mealtime change, was identified and showed that depending on where the families were in the dementia process their experienced varied. As progression occurred in the partners disease, routines, responsibilities and relationships were affected within the couple. Strategies the participants used tomanage mealtimes at home regarding these problems were highlighted such as getting support from social services, but also strategies they had learnt by themselves. Conclusion: These results generate an insight into what couples face, and their needs for support. Spouses experiences varied which indicates that it is important that support is based on individual needs. Hence, nursing staff should continuously pay attention to couples mealtime situation. Further it increases staff´s knowledge regarding possible solutions on how to involve persons with dementia in mealtime activities and maintain their nutritional intake.
Dementia commonly leads to difficulties in performing daily activities, which can also often affect the ability to prepare and eat meals. As a result, formal support to maintain good nutritional intake might be needed, but there is a lack of knowledge concerning how to support older persons with dementia living at home. The aim of this study was to explore and describe staff views on how to improve mealtimes for persons with dementia who are still living at home. A qualitative descriptive study was performed and data were collected during 2011–2012 through four focus group interviews with staff working in the homes of persons with dementia. Data were analyzed using inductive content analysis. The participants described several ways to improve mealtimes for persons with dementia and advocated adjustments facilitating the preservation of the persons' independence. Finding suitable actions calls for knowledge about the person and his/her individual situation. Proposed actions were enabling meals at home, taking over, and moving meals outside of the home. In addition, it was found that, the types of meals served to these persons should be as familiar to the individual as possible. The results of this study indicate the importance of using a person-centered approach and meeting the individual needs when supporting people with dementia in regards to their meals when living at home. Individualized care in the home may be expensive, however, it is fair to say that people who become malnourished and admitted to hospitals is even more costly. Furthermore, sharing and reflecting experiences and knowledge can assist staff to identify ways to manage complex situations. Therefore, the use of refection should be a part of staff members' everyday work.
AIM: To capture the self-description of managing mealtime tasks by persons with dementia.
BACKGROUND: There are several factors that negatively affect food intake in persons with dementia that may increase the risk of developing malnutrition. Difficulties in managing daily activities increase gradually and mealtime tasks like food shopping, cooking and eating often become troublesome. Still, little is known about how persons with dementia themselves experience this issue.
DESIGN: A qualitative study with an ethnographic approach.
METHOD: Ten women and five men aged 69-86 with dementia were interviewed. Interviews were carried out in the informants' own homes and a thematic analysis was performed.
RESULTS: The informants described that they wanted to be independent and that the memory loss was not affecting them to a great extent. Old habits and routines, as well as newly developed strategies, helped them manage mealtime tasks despite the disease. Informants were satisfied with their current situation, even though it sometimes meant that they had changed their way of managing mealtime tasks, for instance receiving meals-on-wheels.
CONCLUSIONS: Persons with dementia seem to be able to manage mealtime tasks and these activities were based on old habits and routines. Independence was highly valued and managing mealtime tasks seems to be one way to appear independent.
It is important for caregivers to understand that persons with dementia might not express difficulties in managing mealtime tasks for fear of losing their independence. It is, therefore, important to create a trustful relationship even before problems arise to be able to support the persons when necessary.
Poor nutritional status is common among persons with dementia and negatively associated with subjective health, mobility and mortality. When malnutrition occurs it is challenging to improve the nutritional status. The aim of the study was to investigate if a structured preventive care process could increase body weight, among persons with dementia at risk of malnutrition or malnourished. The structured preventive care process includes four steps which have been registered in a national quality register: 1) Risk assessment by Mini nutritional assessment-Short Form. 2) Team-based analysis of underlying causes (19 evidence-based risk factors) performed by staff including professionals like nurses, nurse assistants, occupational therapists and physiotherapists. 3) Planning and performing interventions based on the need and problems of the individual (28 evidence-based actions) and 4) evaluation of performed interventions (body weight). A prepost design was used with body weight measured during baseline (0) and follow-up (7–106 days later). In total 526 persons with dementia at risk of malnutrition 176 The Gerontological Society of America Copyedited by: OUP at :: on January 10, 2017 http://gerontologist.oxfordjournals.org/ Downloaded from or malnourished, 65 years and older and with a care contact, were included. Results: 109 persons was registered in all four steps i.e. a team-based analysis of underlying causes have been performed. An improvement in the nutritional status was observed in these individuals (baseline Md 60.0 kg; follow-up Md 62.0 kg; p-value 0.013). No improvement was detected among those missing an analysis of underlying causes. Accordingly, by planning care in a structured way and give individualized interventions based on underlying causes can help improve nutritional status among persons with dementia at risk of malnutrition or malnourished.
Objectives: To describe health care staff members' usage and documentation in a Swedish quality registry focusing on a preventive care process regarding the risk area of malnutrition among persons with dementia. The preventive care process includes risk assessment, analysis of underlying causes, planning and performing interventions, as well as evaluating effects.
Methods: Data were collected from 2 Swedish quality registries, Senior Alert and the Swedish Dementia Register (Svedem). In total, 1929 people with dementia were assessed and 1432 registered as being at risk of malnutrition or malnourished.
Results: Performed nutritional interventions were registered in approximately 65% of cases. In more than 80% of registrations, the analyses of underlying causes were missing. Those who had registered underlying causes had significantly more interventions and the evaluation of the performed intervention was registered. The time between assessment and evaluation depended on care setting and ranged from 0 to 702 days.
Conclusions: Limitations in registration were noted; however, the register allows staff to focus on nutritional care and has resulted in many risk assessments. Rarely people were registered in all steps of the preventive care process. Large variances in when the performed interventions were evaluated makes it difficult to measure improvements.
OBJECTIVE: The aim of the study was to investigate the outcome of change in body weight associated with use of a structured preventive care process among persons with dementia assessed as at risk of malnutrition or malnourished. The preventive care process is a pedagogical model used in the Senior Alert (SA) quality register, where nutrition is one of the prioritized areas and includes four steps: assessment, analysis of underlying causes, actions performed and outcome.
DESIGN: An analysis of data from SA with a pre-post design was performed.
SETTING: The participants were living in ordinary housing or special housing in Sweden.
PARTICIPANTS: 1912 persons, 65 years and older, registered in both SA and the dementia quality register Svedem were included.
INTERVENTION: A national preventive care program including individualized actions.
MEASUREMENTS: The Mini Nutritional Assessment-Short Form was used to assess nutritional status at baseline. Body weight was measured during baseline and follow-up (7-106 days after baseline).
RESULTS: 74.3% persons were malnourished or at risk of malnutrition. Those at risk of malnutrition or malnourished who were registered in all four steps of the preventive care process, increased in body weight from baseline (Md 60.0 kg) to follow-up (Md 62.0 kg) (p=0.013). In those with incomplete registration no increase in body weight was found.
CONCLUSION: Using all steps in the structured preventive care process seems to improve nutritional status of persons with dementia assessed as at risk of malnutrition or malnourished. This study contributes to the development of evidence-based practice regarding malnutrition and persons with dementia.
Aims and objectives. To develop evidence-based guidelines for adult patients in order to prevent urinary retention and to minimise bladder damage and urinary tract infection.
Background. Urinary retention causing bladder damage is a well known complication in patients during hospital care. The most common treatment for urinary retention is an indwelling urinary catheter, which causes 80% of hospital-acquired urinary tract infections. Appropriate use of bladder ultrasonography can reduce the rate of bladder damage as well as the need to use an indwelling urinary catheter. It can also lead to a decrease in the rate of urinary tract infections, a lower risk of spread of multiresistant Gram-negative bacteria, and lower hospital costs.
Design. An expert group was established, and a literature review was performed.
Methods. On the basis of literature findings and consensus in the expert group, guidelines for clinical situations were constructed.
Results. The main points of the guidelines are the following: identification of risk factors for urinary retention, managing patients at risk of urinary retention, strategies for patients with urinary retention and patient documentation and information.
Conclusion. Using literature review and consensus technique based on a multiprofessional group of experts, evidence-based guidelines have been developed. Although consensus was reached, there are parts of the guidelines where the knowledge is weak.
Relevance to clinical practice. These guidelines are designed to be easy to use in clinical work and could be an important step towards minimising bladder damage and hospital-acquired urinary tract infections and their serious consequences, such as bacteraemia and the spread of multidrug-resistant bacteria in hospitals.
Objective: To investigate patients who called the emergency medical services (EMS) for primary healthcare (PHC) problems.
Design: A retrospective and exploratory patient record study from an EMS perspective, comparing two groups: those who were potential candidates for PHC and those who were not. All data were gathered from EMS and hospital records.
Settings: The study was completed at the EMS and five hospital areas in the western region of Sweden.Subjects: The patients (n=3001) who called the EMS in 2011. Data were missing for 10%.
Main outcome measures: The frequency and the clinical characteristics of the patients who called the EMS and were actually potential candidates for PHC.
Results: Of a total of 2703 patients, a group of 426 (16%) were assessed as potential candidates for PHC and could thus be treated at a level of care other than the emergency department. Patients who were classified as suitable for PHC were found at all priority levels and within all symptom groups, but were younger and healthier than the other group.
Conclusion: Numerous patients seeking help from the EMS do not end up at the most appropriate level in the healthcare system.
Implications: In the EMS, guidelines are needed to enable pre-hospital emergency nurses to assess and triage patients to the most appropriate level of healthcare.
There is a lack of qualitative studies exploring the phenomenon of positive ethical climate and what is perceived as promoting it. Therefore, the aim of this study was to explore and describe actions that acute care ward nurses perceive as promoting a positive ethical climate. The critical incident technique was used. Interviews were conducted with 20 nurses at wards where the ethical climate was considered positive, according to a previous study. Meeting the needs of patients and next of kin in a considerate way, as well as receiving and giving support and information within the work group, promoted a positive ethical climate. Likewise, working as a team with a standard for behaviour within the work group promoted a positive ethical climate. Future research needs to investigate other conditions that might also promote a positive ethical climate.
Aim. The aim was fivefold: to describe Swedish nurses' perceptions of moral distress and determine whether there were differences in perceptions depending on demographic characteristics and to describe the usability of the Moral Distress Scale in a Swedish context. Further, the aim was to describe Swedish nurses' perceptions of ethical climate and the relationship between moral distress and ethical climate.
Background. Moral distress has been studied for more than two decades and the Moral Distress Scale is the most widely used instrument for measuring it. Moral distress has mainly been studied in relation to nurses' characteristics, but increasing attention has been paid to contextual aspects, such as ethical climate, that could be associated with moral distress.
Design. Descriptive, with a quantitative approach.
Methods. The study used two questionnaires: the Moral Distress Scale and the Hospital Ethical Climate Survey. The study was carried out at two hospitals in Sweden and included 249 nurses.
Results. Both level and frequency of moral distress were low, however level of moral distress was high in situations when the patient was not given safe and proper care. Generally, the frequency of moral distress was lower than the level. Of the situations on the Moral Distress Scale, 13 of the 32 were considered irrelevant by 10-50% of the participants. The more positive the ethical climate was perceived to be, the less frequentely morally distressing situations were reported.
Conclusions. Since a positive ethical climate was associated with less frequent occurencies of moral distress, it should be investigated what contributes to a positive ethical climate. To be used in a Swedish context, the Moral Distress Scale needs further revision.
Relevance to clinical practice. Open dialouges at wards are encouraged regarding what practices contribute to a positive ethical climate.
Background: Chest pain is a common symptom among patients contacting the emergency medical services (EMS). Risk stratification of these patients is warranted before arrival in hospital, regarding likelihood of an acute life-threatening condition (LTC).
Aim: To identify factors associated with an increased risk of acute LTC among patients who call the EMS due to non-traumatic chest pain.
Methods: Several databases were searched for relevant articles. Identified articles were quality-assessed using the Scottish Intercollegiate Guidelines Network checklists. Extracted data was analysed using a semi-quantitative synthesis evaluating the level of evidence of each identified factor.
Results: In total, 10 of 1245 identified studies were included. These studies provided strong evidence for an increased risk of an acute LTC with increasing age, male gender, elevated heart rate, low systolic blood pressure and ST elevation or ST depression on a 12-lead ECG. The level of evidence regarding the history of myocardial infarction, angina pectoris or presence of a Q wave or a Left Bundle Branch Block on the ECG was moderate. The evidence was inconclusive regarding dyspnoea, cold sweat/paleness, nausea/vomiting, history of chronic heart failure, smoking, Right Bundle Branch Block or T-inversions on the ECG.
Conclusions: Factors reflecting age, gender, myocardial ischemia and a compromised cardiovascular system predicted an increased risk of an acute life-threatening condition in the prehospital setting in cases of acute chest pain. These factors may form the basis for prehospital risk stratification in acute chest pain.


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At Centerbase, our employees are more than part of a team; they're part of a purpose. Centerbase prides itself in being fast-growing, innovative, and unique - and our employees are no exception. Our team works together to build a product that's not only changing the legal landscape but improving it.
In the past year, Centerbase has experienced rapid growth. From expanding our software to introducing a Partner channel of over 90 consultants, we're constantly looking ahead and moving forward, and we're excited to keep adding the best and brightest to our team.
Ready to make your next big career move? Join Centerbase today.
We don't believe in linear paths at Centerbase. You have the opportunity to try your hand at anything that interests you; whether or not it fits into a specific job description.
You won't have to wait around to see your work in action. At Centerbase, you have the opportunity to see your direct impact on the every day successses of the company.
We offer competitive pay, comprehensive benefits, and an open office environment where your work can be seen and your voice can be heard.
Centerbase boasts a tight-knit group of employees who bring their passion, hard work, and fun-loving spirit to our company culture. From team meetings to company outings, we believe in engaging our employees in and out of the office.

subset: commoncrawl


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A successful college fantasy football draft doesn't occur without a good knowledge of each team players are selected. We've listed out our projected depth chart for each of the power 5 conferences for offensive skill positions. Not listed are the defensive depth charts and the offensive line. The importance of a good(or bad) offensive line cannot be overstated when selecting a skill position player.
Mountain West
- 2020 RB Rankings – Top 30 College Fantasy Football - March 22, 2020
- 2020 SEC Depth Charts Updated! - March 21, 2020
- 2020 QB Rankings – College Fantasy Football - March 19, 2020


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About the Author:
Cynx is an American who mainly makes British scenarios for Train Simulator for a wide variety of routes and eras, although as a hobbyist software developer and basic 3D modeler he has published some other bits online. All of his scenarios are made as realistic and engaging as he possibly can, using various resources such as Realtime Trains, CWNs, ABRail, and more.
Find more of CYNX's content,including scenarios and much besides at:
Cynx also has his own Facebook Page where he posts updates and more:
Cynx also has his own Facebook Page where he posts updates and more:
EMR Liverpool to Manchester Scenario Pack (2019)
[CW] 1S50 16:10 Victoria - Ramsgate
Good evening driver. Tonight you will drive 365514 on a semi-fast service from Victoria to Ramsgate, although you will drive only as far as Faversham before being relieved. You will call at Bromley South, Longfield, Meopham, Rochester, Chatham, Gillingham, Rainham, Newington, Sittingbourne, and Teynham along the way. Please note: This is a guard-operated service, so press Ctrl+R before opening your doors at Victoria. Good luck!
80 minutes
Route Used:
2012 London Victoria & St Pancras to Faversham (& Sheerness)**
** Sheerness extension not required for this scenario!
London to Faversham High Speed
Chatham Mainline: London to Gillingham OR Medway Valley Line
ECML: London to Peterborough
Southeastern Class 465
Class 421
Class 423
Class 455/9*
Armstrong Powerhouse
Class 205 Pack*
Class 456 Pack
Class 365 Enhancement Pack
Class 365/465/466 (Met-Cam) Sound Pack (Extra Stock)
Steam Workshop
2012 London Victoria & St Pancras to Faversham (& Sheerness)**
Vulcan Productions – Ash992478
Class 365 Pickup Shoe Patch
*These items are STRONGLY recommended, but should not affect gameplay if not owned. (Either static consists, non-interfering AI, or optional patches)
**The Sheerness Extension route is not required for this scenario to work.
[GBS] Toothpaste Trip (2 Part Scenario)
This is a 2 part scenario which spans South Western Expressways and the PDL. Drive a Class 159 on 1O60 from Bristol Temple Meads to London Waterloo, which will be coupled up to another unit at Salisbury. This service calls at Keynsham, Bath Spa, Bradford-on-Avon, Trowbridge, Westbury, Warminster, Salisbury, Andover, Basingstoke, Woking, and Clapham Junction. You will drive the portions between Bristol-Westbury and Woking-Waterloo.
Part 1:40 mins
Part 2:30 mins
Routes Used:
Part 1: South Western Expressways
Part 2: London Waterloo to Portsmouth
High number of requirements,please see manual


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"Where dreams and adventures come together!"
Bucket List Lodge is a new website, for a brand new adventure. The hunting lodge is located in Saskatchewan, catering to clients who wish to have the hunt of a lifetime. Looking for a modern, but rustic outdoorsy feel, with vivid imagery – Darin Placsko and his partners Pat and Jon Kohls worked closely with BlackSun's Design and Development team to bring their brand and vision to reality.
Standard Features
- Responsive – as with all BlackSun Design websites, the Bucket List Lodge site is responsive to allow a consistent experience across multiple platforms. Content adjusts in placement and size to be more convenient for viewing on smaller devices – but is not hidden and does not vanish. All functionality remains consistent and available to users regardless of their hardware choice.
- Giving Back Stories – The Bucket List Lodge site utilizes a modified blog theme to allow Editors to record their Giving Back Story and hunt gallery every year.
- Flexible Content – The BlackSun Design Flexible Content Setup allows editors full control over their layout – allowing them to choose from pre-designed components to suit their content needs. Editors can choose from free form editors, carousels, buttons, galleries and more to create new content of their choosing while maintaining a consistent look and feel to the website without ever needing to look at or edit "code".
- BlackSun Theme Options – The BlackSun Design Theme Options allow easy editing of "design elements" such as adding a new logo, adding new social media platforms or changing background images with a click of a button.


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2020 BMW 5 Series Grans Turismo Review – Part sport car and part hybrid, the BMW 5 Series Gran Turismo combines the previous' athletic handling with the last's higher ride and more noteworthy cargo-carrying adaptability. The outcome is a spacious, if to some degree ungainly, extravagance hatchback that packs a genuine execution punch. The 5 Series GT's mark utility component is a double mode hatchback that can be either partially opened (like a vehicle's trunk top) or lifted up totally to go up against bulkier things. In the engine, in the interim, there's a decision of turbocharged engines that give official class acceleration.On the drawback, the 5 Series Gran Turismo is excessively tall and overwhelming, making it impossible to be genuinely lively, and it's not as flexible the same number of hybrids. Be that as it may, in case you're looking for a moderately functional extravagance vehicle with a flawless execution family, this multi-capable BMW could be a pleasant fit.
2020 BMW 5 Series Grans Turismo Review
Gone are the times of the BMW 5 Series Grans Turismo, which took the acclaimed solace and drivability of the 5 Series and included huge amounts of additional space. Presently we have the 2020 BMW 5 Series Grans Turismo Review, a 5-entryway liftback much the same as the Porsche Panamera, just taller and less execution centered. In light of the past age 7 Series, it's tall, ample, and highlights a twofold sheet raise opening that can work as either a trunk top or an incubate. Introduced in 2009, the 5 Series Gran Turismo will probably be supplanted by a 6 Series form in the precise not so distant future, so the 2020 model remains to a great extent unaltered from a year ago. It's intended for the individuals who require more space than the customary 5 Series offers yet who don't need the additional mass and stature of a genuine SUV—despite the fact that this intended interest group must not be especially substantial, as it hasn't sold and in addition others in the lineup. A 3 Series Gran Turismo additionally takes after a comparable idea.
2020 BMW 5 Series Grans Turismo Engine
The BMW 5 Series Gran Turismo is offered in either 535i or 550i trim. The 535i is controlled by a turbocharged 3.0-liter inline six-cylinder engine that puts out 300 drive and 300 pound-feet of torque, while the 550i gets a twin-turbocharged 4.4-liter V8 useful for 445 hp and 480 lb-ft. An eight-speed programmed is the main transmission offered, however purchasers can browse standard back wheel drive or available all-wheel drive ("xDrive" in BMW-talk).
All 5 Series Gran Turismos are exceptionally very much prepared. The 535i accompanies 18-inch alloy wheels, versatile xenon headlights, an all encompassing sunroof, front and back parking sensors, double zone programmed atmosphere control, cowhide upholstery, Bluetooth, the iDrive gadgets interface with route and a 12-speaker stereo with a helper sound input jack. The 550i includes the gutsy V8 engine, in addition to 20-way control front seats and a rearview camera. The choices list for the two models is long and includes things like a versatile suspension, premium sound and a night-vision camera.
See also 2020 BMW 4 Series Design Review, Price and Specs
2020 BMW 5 Series Grans Turismo Interior
Inside the 2020 BMW 5 Series Grans Turismo Review you'll find top-quality materials and grown-up measure space for both front and back seat travelers. The secondary lounge specifically is tremendous. Folding the back seatbacks down makes a solid 62 cubic feet of cargo space that is effectively gotten to through the substantial back incubate. On the off chance that you don't require very that much cargo room, the 17.7-cubic-foot consistent cargo hold can be gotten to from either the full incubate or the trap half-bring forth that opens more like a customary trunk.In reviews, we've discovered that the 5 Series Gran Turismo strikes a quite pleasant harmony amongst physicality and ride comfort. Contrasted with the 7 Series, the ride quality is a bit on the firm side, and the car's additional pounds and taller profile combine to deliver more body move than you'd involvement in a BMW. All things being equal, this peculiar expansion to the 5 Series lineup offers a surprising combination of sportiness, common sense and extravagance.
The component list includes such luxuries as journey control, Dynamic Drive Control, an all encompassing glass sunroof (discretionary), four-zone atmosphere control, electronically retractable sun shades, versatile bi-xenon headlamps, programmed back end activity, Comfort get to, head-up show, raise see camera, satellite route, lumbar help, DVD changer, six-CD tuner, electronically movable front seats with two memory settings and lumbar help, electric tilt/slide sunroof, high-shaft help, and also Bluetooth and USB sound interfaces.Entry and departure are additionally perceptibly loose on account of cunning ergonomics and a marginally hoisted seating position. BMW allude to this as the "semi-order position".As well as being reasonably prepared where hardware is concerned, the car's touring center is additionally solid with an undeniable and sharp accentuation put on cabin's atmosphere, styling and practicality.Rear seating is especially alright with liberal extents (especially so with the availability of a discretionary, devoted four-situate cabin – not imagined), while the tilt point of the back seat backrest and fore/toward the back development of the seat pad is likewise conceivable.
2020 BMW 5 Series Grans Turismo Exterior
In keeping with BMW's EfficientDynamics theme for greener, less fatty motoring, the 5 Series Gran Turismo extend offers outstanding mileage figures additionally helped by natural innovations that include Automatic Air Vent Control and Low Rolling Resistance Tires (on the 530d Gran Turismo just), in addition to Brake Energy Regeneration and the up to mentioned eight-speed programmed transmission (all models), and also High Precision Injection (on both petroleum fueled variations).
BMW has a very much earned notoriety for building adjusted, sharp-handling drivers' cars, however the 5 Series Gran Turismo's driving elements have demonstrated a bit of a disappointment to street analyzers. The car rides well, however its additional stature dislodges its weight too far-removed the ground and its handling is more similar to a SUV than a games vehicle. To help with that, BMW offers overhauled 19-inch wheels, a versatile suspension, and a 4-wheel steering system that BMW calls Integral Active Steering.The 5 Series Gran Turismo's extravagant interior, construct to a great extent in light of that of the old 7 Series, seats 5 travelers, with a lot of leg-and headroom. The car offers 17.7 cubic feet of cargo space available through a power-worked bi-modular trunk entryway. The back seats can be set down for extra room, however the 5 Series Gran Turismo simply doesn't have the cargo limit of a SUV or a legitimate station wagon.
2020 BMW 5 Series Grans Turismo Release Date and Price
BMW as of late took the wraps off the all-new 2020 5 Series Gran Turismo, with its athletic and streamlined outline and abnormal state execution. It combines the long-remove solace of an extravagance car with the tasteful interest of a roadster, while delivering a dynamic driving knowledge with its TwinPower Turbo innovation and intelligent lightweight suspension development. The 2020 BMW 5 Series Grans Turismo Review, which will be offered solely as a BMW 640i xDrive demonstrate, will be released in the fall of 2020. Pricing begins at $69,700 in addition to $995 Destination and Handling.


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The Choir sings at every 9.30 Mass on Sundays as well as Holy days and the major liturgical celebrations of the Church.
Rehearsals take place every Thursday from 7.00 – 8.30pm.
Singers Wanted!!!
The choir is always looking for new members of all ages to join and would be keen to hear
from anyone that is interested.
You do not have to be able to read music or have any previous musical experience to join. If
you enjoy singing and are interested in learning something new, then why not give it a try.
Please speak to any member of the choir if you would like to be involved.
St Augustine: "He who sings, prays twice".
The choir currently has around 16 members and sings a varied repertoire of music.
We now also have a Junior Choir that occasionally sings at the 9.30 Sunday Mass. This is made up of students from St Bede's Primary School, who rehearse on Monday's after the school day.
If you have any enquiries with regards to music at St Bede's please contact Paul Brennan, Organist & Choirmaster: Contact
The William Hill & Son and Norman & Beard Pipe Organ is located in the gallery at the back of the
church. The organ was moved from St Pauls Church, Great Yarmouth in 1993/94 by Aistrup
& Hind church organ builders who maintained the organ until 2015 . The origins of the
organ date as far back as 1907 and, after being rebuilt in the early 1950's, the opening recital was
performed by Reginald Foort (the BBC Theatre organist).
The restoration of the Organ has now been completed after a 10 month project.
Please see below for details and pictures of the project and the end result.


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Let's be honest. Everything in your bean garden is dead. It's the middle of winter, I can hear what you're saying. "We're tired, we've had enough!" So I reckon take the month of June off gardening and go learn a new skill like crochet. It's a dying art form. Who do you know apart from me, and maybe your dead grandmother that can crochet? Think about it, I envisage that crochet will be huge in ten years. Think of the potential earnings if you can become an expert in the artform this month. Good luck!
If attending the annual bean farmers conference, bring a plate a beans (you may have to open a jar of preserves – I know it's difficult), and a bad attitude for three days of intensives where we subject various political leaders from across the political spectrum to constant abuse and an endless rampaging torrent of vitriol because of the lack of support for Market Gardeners.


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When we talk about Kali Linux, we mean one of the most important and best known ethical hacking suits worldwide. It offers a wide range of possibilities to users and that makes each new version make many are attentive to their news. In this article we echo the
news of Kali Linux 2019.3, as well as explain how we can download this Linux distribution.
As often happens with each new update, whatever the type of program or system, they bring improvements. These improvements translate into new functions or tools that make the day-to-day life of users benefit. But you also have to keep in mind that with each new version, present problems are corrected.
Kali Linux allows users to perform different ethical hacking tests. Now they have a series of novelties that make this Linux distribution even more attractive. We are facing the third update of this current version. We will comment on the most important changes.
What's new in Kali Linux 2019.3
One of the novelties of Kali Linux 2019.3 that we can mention is that they have started using
Cloudflare CDN to host the repository and distribute content to users. This they do to improve the quality and speed of downloads.
There are also changes regarding
metapackages. Now there is an additional and unique image called kali-linux-large-2019.3-amd64.iso.
Kali Linux 2019.3 is not a great update that brings very significant changes, however it
has improved certain applications. For example we talk about tools like Burp Suite, HostAPd-WPE, Hyperion, Kismet and
Nmap. All of them have been updated to a new version and have included improvements.
One of the significant changes in relation to applications is that it now includes
Amass. It is a tool that security professionals can use to map the network and discover possible external threats. Now this tool comes standard with Kali Linux.
For the rest, it should also be mentioned that improvements have been made in terms of failures and security errors. Corrections that, in short, make this new version safer.
How to get Kali Linux 2019.3
It should be mentioned that for those users who already have this distribution installed and have it updated they will not have much to do. They would simply have to run the root @ kali command: ~ # apt update && apt-and full-upgrade to make sure they have the most current version.
For those users who do not have it installed or want to obtain the ISO for some reason, it is best to go to the official website . There you just have to go to the download section and download the version you want (64 bits, 32 bits ...).
For those users who do not have it installed or want to obtain the ISO for some reason, it is best to go to the official website . There you just have to go to the download section and download the version you want (64 bits, 32 bits ...).
As we always say, it is important to download software from official and reliable sites. We must avoid doing it from third-party links that we don't really know who it belongs to and what could be behind it.
In addition, having updated systems can bring important benefits. On the one hand we will have the most updated tools and thus obtain improvements in performance. However, security is also very important. Security vulnerabilities are corrected with each new update . Faults that can be exploited by cyber criminals and that have been patched.


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Remember when Caroline freaked out about the upcoming hearing/vision screening at school? Well, I had planned on completely "forgetting" about it and not saying a word to her about it as it loomed and I actually ended up truly forgetting about it, so when I got home from work yesterday and Jason handed me the results of the screening, I looked at him and said, "Well?????" He just smiled and said, "Ask her."
So I did, and the response?
"Oh mommy, it was the most fun thing EVER! I wanted to do it over and over and over! I LOVED having my vision and hearing checked!!"
Um, isn't that EXACTLY what we told her? That it would actually be kind of fun and that when we were in school we always liked it? Typical Caroline! But at least now, we can remind her of this and how she worried so much for nothing. I told her she needs to trust Mommy and Daddy since we went through a lot of this before. I understand the anxiety of the unknown, but this really was nothing. Oh my sweet girl - she's more like me than I realize I think.
Her hearing was fine and her vision was 20/30 so glasses may be in her future. Or not. At least we don't have to worry the next time they "threaten" her with a screening.


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Download your FREE report on wing chun essentials:
10 Wing Chun Kung Fu Training Principles Any Martial Artist Can Use!
All Shaolin monks know of this subset of their style of kung fu, but few earn the right to learn this hidden aspect of Shaolin training. Most don't even try to for one simple reason: Buddhists strive to be passive. They vow to live by 200-plus religious laws, an endeavor that requires extreme discipline and dedication. Not everyone who's accepted into Shaolin takes a liking to monastic life. Many find the restrictions of Shaolin training and the routine too taxing and drop out. The techniques that make up lethal Shaolin are taught only to the monks who don't quit. To reach that level of Shaolin training, a monk must convince his masters that he's on the right path spiritually.
Download this FREE Guide:
Eric Oram Shows You How to Fight Someone Bigger Than You
Using Wing Chun Techniques!
- 1. It is the desire of the monks at the temple to remind the public that all the legends they've heard about Shaolin's fighting prowess are true.
- 2. Any martial artist will attest that knowing the movements is one thing, but mastering them to the point at which they can be used in a fight is quite another. In other words, it will take a lot of practice under a qualified instructor for these techniques to be effective.


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When it comes to glamping in Gloucestershire, Cherry Tree Glamping enjoys the very best setting, marrying a rural idyll with easy connections – Stroud, Cheltenham, Cirencester and Gloucester are all under 20 minutes' drive away.
Places to eat
Our local pub, the Butchers Arms, is a traditional Cotswold inn with plenty of personality, top-notch ales including local brews, and superb fare that's definitely a cut above. What's more, it's only a short walk from our site, so you can stroll down and make a night of it.
As you probably know, we're right in the heart of Laurie Lee country (we even named our beautiful gypsy caravan, Rose, after his most famous book, Cider with Rosie). Laurie's cherished local, the 300-year-old Woolpack in Slad, is another popular place for a pint and a plate of food. There are plenty of places to eat in Stroud, too – we love Falafel Mama and Star Anise Arts Cafe, as well as Lavender Bakehouse in Chalford – but you're sure to find something that suits your tastes.
If retail therapy is your preferred way to unwind, you've come to the right place. Nearby Stroud plays host to Shambles Market and a farmers' market at Cornhill on Friday and Saturday respectively and offers a range of high-street and independent shops all year round. Cheltenham offers all the chain stores and some very upmarket boutiques as well as the lively Brewery Quarter which offers a cinema, indoor crazy golf, and a range of restaurants and shops. Whatever your Cotswolds shopping style, it's all within easy reach.
Art buffs will find plenty to occupy them during their Stroud glamping stay – there must be something in the landscape that inspires the many creative types who cluster here. Visit Pegasus Arts for one of the widest ranges of arts materials in the Cotswolds, get hands-on at a workshop at the Centre for Science and Art or Atelier, or see a show or a live band at Stroud's Subscription Rooms or the Playhouse in Cheltenham.
Delve into fascinating Cotswold history with a trip to one of Gloucester's many museums, or head for the superbly named Hetty Pegler's Tump near Uley.
Painswick, Queen of the Cotswolds
Nearby Painswick is the epitome of a quaint Cotswold village, and offers a few super eating options including the elegant Falcon, the homely and dog friendly Painswick Pooch, St Michaels for foodies, or Olivas for coffee aficionados (it's run by a Colombian!). There's also the brilliant and quirky Rococo Gardens, famous for its annual show of snowdrops.
Gloucester and Cheltenham
Gloucester and Cheltenham are within easy reach by car or bus, and there's plenty to occupy solo travellers, couples and families in both. Glorious Gloucester Cathedral was used as a set for the first two Harry Potter films, and there are several excellent museums in the city; the newly developed dock area incorporates the National Waterways Museum and some jazzy bars and restaurants, including a cafe on a narrowboat. The regency town of Cheltenham is famous for its fantastic festivals; Literature, Jazz, Music and Science - they're all well worth the trip if you're staying with us while they're on. It's also the birthplace of Gustav Holst, composer of the Planet Suite.
Gardens, Houses and Walks
If outdoor pursuits are more your thing, we have some fabulous walks right from our doorstep. We're not far from the Cotswold Way, so you can easily access and walk some sections of the 100-mile National Trail. Newark Park (National Trust), Woodchester Mansion, and Berkeley Castle are all a short drive from our site. The internationally renowned Slimbridge Wetland Centre is about 20 minutes away; you can watch the adorable otters being fed or indulge in some serious bird-watching.
Further Resources
Find out more about what's going on at Visit the Cotswolds or So Glos websites – or just bring a good book and stay on site!


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Smile Crystal
Sold out
Available soon$168.00 $210.00
ReviewsNo reviews
Details & Fit
Designed for Spring/Summer 2018 collection, Smile is a fresh contemporary frame that captures the iconic aesthetics of the 90s. The model features a low profile, firm rims and a straight upper line supported by a sturdy nose bridge. This version of the model features a minimal crystal acetate with fresh orange tinted lenses. The box contains a soft case and a cleaning cloth.
Size: R
Lens Width: 54mm
Frame Front: 130mm
Frame Side: 130mm
Product Code Size R: 3AV
See size guide
Shipping & Returns
Free shipping on all orders. We ship worldwide, with the exception to Russia and Brazil. A shipment usually takes around 2 working days in Europe and 5 working days worldwide.
If for any reason you are not satisfied with the product, you can return it within 15 days of delivery. Please contact our customer service.
Copyright © 2020 RETROSUPERFUTURE® P.IVA IT06267680962 Terms of use / Privacy policy EU regulations


text: Fortnite: Blackhole broke records on Twitch and Twitter, says Epic At Fortnite, the event around the "Black Hole" has broken some records. As Epic now reports, records fell on Twitter and Twitch for "The End." It was the biggest gaming event ever – it was huge on YouTube, too, but pop stars like Beyoncé are even bigger. Where does the information come from? The information comes from Epic itself. We already knew that many people had watched the mysterious event on social media – we now find out how many it really was. Speaking to The Fortnite Account Generator, it is clear that more than 7 million people watched the event simultaneously on Twitch, Twitter and YouTube. The event has now broken records on Twitch and Twitter At YouTube, the biggest platform, it was at least at the top. There, however, live events are even bigger if Beyonce performs somewhere. Here's what Epic says: On Twitch, 1.7 million people would have watched either the official Fortnite stream or a streamer that had hired Fortnite. That's a record for the "peak attendance at a single game." On Twitter, the "black hole" would have been the most-watched gaming event, with over 50.7 million minutes watched and 42.8 million views. There was a peak of 1.4 million simultaneous viewers On YouTube, the event garnered 4.3 million simultaneous viewers. Fortnite 'sent' players out of the game on social media Why was the event so successful? Epic had previously announced the event and a one-week countdown counted down to 8 pm our time. There have been such events at the end of a season in Fortnite before. They showed how fortnite's map would change and brought the story of a season to a close. This time, however, the event was particularly enigmatic and ended even more spectacularly than usual: a black hole sucked up the map and no one could play anymore. That moment, when no one could play Fortnite anymore, apparently caused so many to watch this event via YouTube, Twitch, and Twitter to talk to others and see how they reacted or if they knew more in these places. One can probably assume that the record numbers were immediately reached "AFTER" to the event when nothing moved in the game and only the option remained to press and log out to "Exit". It is precisely the "mystery" with this surprising end that has probably provided for the record numbers.


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Lay Summary: Personal history of breast cancer at young age is an indication for BRCA testing.
Personal history of breast cancer at young age is an indication for BRCA testing. The literature variably sets the age of what is considered early at before age 50 or 40.
NCCN guidelines were revised to include the following changes from 2008 version(NCCN 2011):
•Changed age of diagnosis of personal history of breast cancer from 40 years or less to 45 years or less
•Add an indication for two breast primaries, when first breast cancer diagnosis occurred prior to age 50
•Women with triple negative disease under age 60 should have BRCA testing
Removed at least one close male blood relative with breast cancer and at least one close female blood relative breast or epithelial ovarian cancer from qualifying criteria for testing males with breast cancer
•Modified stated of family history to read "if no living family member with breast or ovarian cancer, consider testing family members affected with cancers thought to be related to BRCA1/BRCA2 such as prostate, pancreas or melanoma".
The risk of baseline prevalence of BRCA mutations has been best established in the setting of family history. Personal history is less well attested to in guideline statements than family history but several guidelines do mention this factor. They include the ACS Guideline, NCCN, Hayes. Some guidelines, such as NICE and UPTFS, skirt this issue by deliberately noting that they do not address women with breast cancer at a young age. Nevertheless, BRCA screening is usually considered to be indicated in such cases. Other guidelines also would cover testing for this patient.
The Society of Breast Surgeons adds: "a personal or family history of ovarian cancer (particularly non-mucinous types)". Hayes Genetic Testing Evaluation says: BRCA1 and BRCA 2: The decision to undergo genetic testing for BRCA1/2 variants may be most influenced by physician recommendation for testing and indecision about definitive surgical treatment. In addition, patients younger than 50 years of age at diagnosis and those having multiple primary tumors are more likely to undergo genetic testing for BRCA1/2 variants. However, the recommendation for testing triple negative patients is unique to NCCN at this time, according to my knowledge.
NCCN now includes patients with DCIS disease only, as it does not differentiate between invasive and non-invasive cancer.
NCCN, Screening for breast cancer, BRISK -1, BR-OV 2017
Trivers KF, Baldwin LM, Miller JW, et al. Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians: a vignette-based study [published online ahead of print July 25, 2011]. Cancer. doi: 10.1002/cncr.26166
Robert A. Smith, PhD, Debbie Saslow, PhD, Kimberly Andrews Sawyer, Wylie Burke, MD, PhD (for the High-Risk Work Group), Mary E. Costanza, MD (for The Screening Older Women Work Group), W. Phil Evans, III, MD (for The Mammography Work Group), Roger S. Foster, Jr., MD (for The Physical Examination Work Group), Edward Hendrick, PhD (for the New Technologies Work Group), Harmon J. Eyre, MD and Steven Sener, MD (for The Breast Cancer Advisory Group)American Cancer Society Guidelines for Breast Cancer Screening: Update 2003 CA Cancer J Clin 2003; 53:141-169
J. Balmañaetet al, BRCA in breast cancer: ESMO Clinical Practice Guidelines
Ann Oncol (2010) 21 (suppl 5): v20-v22 K.


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FurryWednesday, February 4, 2015
Fur is a great way to get attention this season. Whether it be a bag, a vest, a jacket, or even a skirt, I always find myself drawn to (faux) furs when I go shopping. It's easy to throw this vest over a simple outfit to pull the look together. It's a great outfit for a day in the city because it's stylish and also practical.
Vest - Tinsel via TJMaxx | | Shoes - Tory Burch | | Sweater - H&M | | Pants - Joe's | | Bag - 3.1 Phillip Lim


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Why a local agency?
Local knowledge
We have a team of travel experts that are based in the respective city where your tour is booked that know all the ins and outs of the place. Our industry expertise, paired with local knowledge, makes our tours unique in a sense that you will get to see more than just typical tourist attractions.
With our agency being based in Spain, we are actively out on the field discovering new paths and itineraries that will make your journey in Spain exciting.
During our tours you will learn first-hand from locals themselves about Spain´s culture and history while creating a special bond with the country.
Book with confidence
We have thousands of visitors coming to Spain that book with us on a yearly basis. We are Madrid-based and resistered under the license number CICMA 2729 meaning you are financially protected if you book with us. We are also a members of ASTA (American Association of Travel Agents).
In the past we have organized corporate events and some of our clients include : Zurich Insurance Group and General Electric, Amadeus IT Group and many others.
Through booking with us, we ensure peace of mind.
Great value
We offer great value on tours, activities and trips. Our travel products have been created through careful and extensive planning by our specialized team to make sure everything runs smoothly. Our customers expected level of satisfaction is always exceeded and we see returning familiar faces every now and then.


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Our Work
Civil Rights
ADC San Diego works with the local chapter of the ACLU to protect civil rights of Arab-Americans in San Diego County. For more information contact our Vice-President Wedad Schlotte, firstname.lastname@example.com.
Police Sensitivity Training
ADC San Diego does cultural sensitivity training for the San Diego Police Department. We educate new SDPD graduates about Arab-American history, try to dispel stereotypes, and call attention to special issues that might arise in interactions with the police. We are looking to expand our training to other police departments in San Diego County. For more information contact Tyseer Odeh, firstname.lastname@example.com.
Refugee Assistance
ADC San Diego sponsors a program to teach English to Syrian refugees. For more information contact our President Doris Bittar, email@example.com.
Promoting Arab Culture
ADC San Diego supports the House of Lebanon, the House of Palestine, and the San Diego Arab Film Festival.


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Cody Garbrandt: No Love in War
Unbeaten as a pro mixed martial artist; became UFC champion in only his eleventh fight; ranked #5 POUND for POUND at the age of 25; involved in two different war of words online whilst out injured
....when will we see the Bantamweight king back in the cage?
After being welcomed to the UFC in January 2015 by Marcus Brimage, coincidentally the same man that faced Conor MacGregor in his Octagon debut, Cody Garbrandt has been on a meteoric rise to the top.
After 5 straight wins, 3 by first-round KO, 'No Love' went on to hand Dominick Cruz his first defeat in almost a decade and become UFC bantamweight champion in December last year.
However, since winning the belt it has been an up and down six months for the man who wears the 135 strap.
Everything seemed set as the Champ was expected to meet fellow "Ultimate Fighter 25" coach and former champion T.J. Dillashaw at UFC 213 in July.
After training together for several years at Team Alpha Male in Sacramento, Garbrandt and Dillashaw now have a 'rocky relationship' at best. Since T.J. left the gym to train with striking coach Duane Ludwig at Elevation Fight Team in Colorado, and the disdain between he and former teammates such as Garbrandt and Urijah Faber has seemingly grown deeper by the day.
Let's be honest, that's why we were all salivating at the thought of these two being locked in a cage together for 25 minutes with a title on the line!!
However, after a well-publicized back injury, that had been affecting Garbrandt throughout his MMA career, required him to undergo stem cell treatment in Germany, the must-see show of International Fight Week was not only derailed but in-turn set off a carnival of events in two divisions.
Since the overseas trip, Garbrandt has admitted the treatment helped a bit with the pain, but he was certainly not healed enough to fight on the scheduled July 9 card.
"I have to take a little bit of time to heal and recover for something that's going to set me up for the next five, 10 years...however long I want to pursue this career and lifestyle."
He added, "I have too sit back and think about the future outside of fighting because this is really a small window frame of my life. It's only going to be a small part, but it is going to set up the rest of my life. So I have to be smart and think about my future. I'm not going to rush this one. I am doing rehab six days a week, strength and conditioning. I'm strengthening my body. It's unfortunate this happened as I was very excited for the fight against T.J."
Garbrandt had said that once he was fit and defeated Dillashaw, that he intended to go after a second belt by dropping in weight and challenging flyweight champion Demetrious Johnson.
This is where things got interesting...
As recently as a few weeks ago, after Garbrandt's injury came to light, the UFC was seeking to book Dillashaw himself v 'Mighty Mouse' for the flyweight title. In fact, Dana White pushed the idea, as did Dillashaw, but with Johnson never on board with it, the plan for an August 19 showdown in Seattle was eventually scrapped.
If Dillashaw had of got a title fight against D.J. and managed to beat him, there is no doubt Cody would have dropped immediately down to 125 pounds to try to take the belt away from him.
'No Love' doesn't seem to care at which weight he faces Dillashaw, as long as he does, and sometime soon. "The last thing I want to do is prolong the fight because of an injury. T.J. has an ass-whooping coming and I want to be 100-percent to give T.J. a 100-percent ass-whooping. I won't be satisfied going in 60-percent and still whooping his ass. I don't want to give him a 60-percent ass-whooping, I want to give him a 100-percent ass-whooping like he deserves"
….that's a lot of ass whooping!
Either way, I know anyone who loves this sport like I do just wants to see Cody v T.J. Whether it be at 125 or 135, hell, I will watch them at a catchweight with no strap on the line. I just want to see these two bang!
When Garbrandt actually returns is still up in the air. He had stated a few weeks ago that he would love to return at UFC 214 in Anaheim, California on July 29, but let's be honest, that isn't going to happen. Not only because it is in 25 days or so but the card is already stacked and has just added two more title fights to go alongside the Jones v Cormier 2 headliner.
Could it be at the newly announced UFC 215 card in Edmonton on September 9th or is it more likely UFC 216 on October 7th as the promotion returns once again the Sin City. Both cards are still without a title fight...until an announcement, we can only wonder?
In his time away from the cage, Garbrandt has not only been at war with Dillashaw on social media but one of T.J. followers, bodybuilder Matthew Kline Kader.
Things kicked off between Garbrandt and Kader during an exchange with Dillashaw and Garbrandt on Twitter, where Cody told his ex-teammate to wait until he returns back to full health instead of opting to fight D.J.
That's when Kader, who goes by the nickname 'Shallow King' and who has 121k followers, interjected and called Garbrandt a 'bitch' for 'backing out' of the fight.
Things escalated from there, as the two traded insults back and forth before Kader promised to fly from Las Vegas to Sacramento on June 25 to challenge Garbrandt at Team Alpha Male, promising to also make an example of coach Justin Buchholz.
The 'International Boss' Kader even went a far as to uploaded a fight poster to Instagram however as June 25 came and went nothing eventuated, with both accusing the other of not turning up at the gym to fight.
Garbrandt: "Coach this guy isn't here I've been at the gym all morning! lol, I just got back from Vegas last night. He is the ultimate troll!"
Kader: "@Cody_Nolove you're the biggest troll in the world the little goofy dorks inside your gym trying to fight your battles"
and; "Fake ass coward fake champion lied to his fans and now the world will see the proof video coming. Done with your coward ass."
While this was entertaining while it lasted I am glad this is behind us. I wasn't sure how long I could deal with Kader, besides the man seems to be too busy for a fight if his Twitter is anything to go by...."I am officially single & I'll be going 6-9 beautiful women every night of the week"
Oh dear.
It hasn't been all online wars for Garbrandt in his time away from competitive action, however.
'No Love' showed he doesn't always live up to his name when he proposed to his girlfriend, Danny Pimsanguan in Sedona, in late April. Garbrandt shared the exciting news in an Instagram post with a pic of the couple and the caption "Soon to be Mrs. Garbrandt".
Well played sir.
To get the inside story on his recovery and what he is doing to return to the Octagon, his experience on TUF 25, his Twitter battles and what he plans on doing next, subscribe to the UFC Channel on PADLOKT.com today to talk with Cody live via video (or watch live via live stream) on July 5 @ 7PM PDT where Cody 'No Love' Garbrandt will answer all your questions.
Whether you're a fight fan or just want the wish the Bantamweight Champion a Happy 26th Birthday for July 7, this is an opportunity you don't want to miss.
Jimmy. R. Nugent
#cody_nolove #jimmy_nuge


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Week 1: J.D. Greear
Race in America is a 3-week course which provides a Christian perspective on America's history and future regarding ethnic relations. Above is the recording of Week 1 of the course, taught by Pastor J.D. Greear.
Come and discuss Black History, White Privilege, Wokeness, together with your fellow believers in a safe and gospel-centered environment. Leave with practical action steps to help make the church, and our society, a multi-ethnic haven.
Join Pastors Chris Green, J.D. Greear and other Summit Leaders for a close look at Race in our society. RSVP here to attend.


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Last night I stopped by the new place to do some measurements and I thought I'd take a few pictures to show you what it looks like. Being there made me so excited to decorate soon!
When you first come in the door, this is the entrance way, with a closet to the left and stairs ahead of you to the apartment. Straight ahead is the bedroom door and beside that is the bathroom door. If you go to the left you'll enter the kitchen.
The kitchen is small, but cozy, with new linoleum floors, dark wood cabinets and a nice new counter top.The fridge is tucked around the corner behind the stove, with more storage overhead. There is still as little storage and counter space as the old apartment, but it looks MUCH nicer. I'm looking forward to cooking up some tasty meals in here.
Beyond the kitchen is my favourite room in the whole apartment. This dining room is FULL of natural light, with lots of windows overlooking a beautiful street full of historic homes that I absolutely adore. I imagine I'll be spending lots of time daydreaming and looking out these windows.
Behind the kitchen, and just off of the dining room is the living room. Again, it has plenty of natural light with two big windows, and they've installed beautiful laminate flooring that has a great whitewashed wood grain look. We plan to make this a living room/home office.
Here is another shot of the dining room, looking back from the living room. I have a big old solid wood table that I found on the side of the road and it has been living in my Dad's garage for two years until I found a place big enough to have it. Now it can come out of storage! It needs to be refinished, but that may have to wait for Spring.
Just across the hall from the living room is the bathroom. Its still a small space, but it has a bigger shower and nicer flooring than my old place. I'm thinking about getting a cabinet to go above the toilet to give us even more storage space.
Right next door is the bedroom. Its a small room (especially compared to my old place), but it has a great closet and beautiful big baseboards.
The bed will be tucked away in this corner, however there isn't enough room for my big headboard, so I'm going to have to make something to go there instead. I'm always up for a challenge!
That's all I have to show you of our little place for now, but I'm sure I'll have more pictures soon. We've already moved in about 1/3 of our stuff and I'm hoping to do another load this weekend, so hopefully we'll be moved in even earlier than we planned!
On my way back home from the apartment I passed this amazing view at sunset that made this whole field look like it was on fire. I can't believe that we'll be living 5 minutes away from all the beauty right now. Its going to be great 🙂


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Live Dream Catcher – Money wheel game for SLOT lovers
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Live Roulette rules in 10 min. (Video)
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Baccarat is a popular card game played in the land-based casinos and is now available in online and mobile casinos. The game has popular variants which are Baccarat Chemin De..


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Pewee Valley Gauge
Fisherville Gauge
Mt. Washington Gauge
Provided by the Kentucky Department of Fish & Wildlife in winter months, hatchery rainbows are a seasonal recreational fish in Floyds Fork and a select number of ponds within The Parklands. While our ponds are incredibly popular for anglers pursuing trout, aside from our resident bald eagles and river otters, I've been surprised by the lack of fishing activity I've seen on the Fork this winter. Low flows, clear water, cool temperatures, diminished recreational boating, and bare trees/shrubs make winter a great time to pursue stocked rainbow trout on Floyds Fork.
With the February stocking upon us, and March stocking just around the corner, I thought I'd share some tips for winter trout fishing on Floyds Fork.
Tip #1 – Know the regulations. First, you must have a valid fishing license and trout stamp to pursue trout in the Fork. These fees pay for the trout you are pursuing. Second, delayed harvest regulations are in place for Floyds Fork trout. You must release all trout caught in Floyds Fork through late spring. This regulation extends the fishing season for anglers by having more fish spend more time in the water before harvest. Use this link to be a responsible conservationist and get the necessary license and permit - Fishing Licenses and Permits
Tip #2 – Take the plunge and use a fly rod. Sure, light action spinning gear works great on the Fork all year long, but winter is the time to pull out the 4-5 weight fly rod. The clear water makes fly fishing the most effective method to increase your catch rate. I will not get into specific fly recommendations, but . . . nymphs, nymphs, nymphs. And mend it, mend it, mend it. (Apologies to Hank Patterson)
Tip #3 – Embrace movement. Unlike pond fishing, successfully finding fish on the Fork means moving around. Whether wading or paddling, when you strike out at a spot for a while, go ahead and move to another. Don't hesitate. Our resident river otters, mink, bald eagles, and blue herons move around to get their fill of fish, and we should follow their lead.
Tip #4 – Know where you are fishing. While people will catch trout throughout The Parklands, most trout are between North Beckley Paddling Access and the Creekside Paddling access in Beckley Creek Park. Also, be sure to check water levels. It is generally best to fish for trout when the water is low and clear. I personally like the water to be flowing less than 50 cubic feet per second for trout fishing. Real Time Water Levels on Parklands Homepage
Tip #5 – Join a local fishing club and visit some of our great local fishing shops to get the most current information. Our local clubs and fishing retailers are great places to get expert local fishing info. They are also the frontline for supporting conservation and public fishing opportunities in our region.
Some Local Fly Fishing Retailers
Area Fishing Clubs
Being a donor-supported public park means we rely on donations, not tax dollars, for annual operations each year. Because of your generosity, we are able to maintain, program, and further develop this extraordinary public space without charging an entry fee. Together we work to enhance quality of life and help our community and economy grow in ways that are healthy, sustainable, and enjoyable for people of all ages. Help us reach our goal of sustaining The Parklands by becoming a Member today. Members make it happen!
Become a Member


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Being A Parent is a wonderful step to take in life. Child-rearing is a rewarding experience but is not without its problems and difficulties. Children at every stage of development exhibit some level of independent thought, and they won't hesitate to let you know that. Look at the useful tips below for ways to handle the problems, challenges and memorable times during your being a parent years.
Consider what you are actually saying to your child. You want your children to know you can be trusted.
It is natural for young children to have a hard time transitioning. Quickly changing from one activity to the next can cause stress and may result in a temper tantrum.
Parents should avoid trying to persuade their teenagers to go to a certain college. Teens who feel that they have to go to a certain college may choose another out of spite, or even opt out of college entirely.
Don't let your child leave for school without reflective tape on his backpack. Put this tape on his clothes, too, for extra protection. You can also purchase this material in Velcro, which will make it easier for your child to strap on. This helps crossing guards and drivers see your kids better, especially when it's early in the morning.
Cucumbers, carrots or sour pickles can be put into a mesh teether and given to a baby who is having a painful time when cutting their teeth. There are many methods that work for relief, but if the item the child is chewing on contains a taste then he will more than likely keep chewing on it. As he does this, he will feel better regarding his teeth.
When driving for long distances with a toddler or young child, make sure you stop often so they don't get bored or irritable. Driving straight through to your destination may seem like the most efficient plan, but a more leisurely approach with down time for the kids will be more enjoyable for all. Stop at parks, restaurants with play areas, or open grassy areas to let your children run off excess energy during the trip.
As this article has demonstrated, raising kids can be extremely rewarding. However, it's extremely stressful at the same time. No matter how many children you raise, there are many challenges to being a parent. When you find yourself grappling with the inevitable dilemmas of being a parent, just follow the advice presented here for successful resolution.


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While admitting that his odometer may be loaded with mileage, Manny Pacquiao remains engrossed in training and treats his January 19 showdown with Adrien Broner as a test for how much farther he can go.
"When you start to age, you listen to your body," Pacquiao told a few scribes after his final training session in Manila.
"You don't train as if you are still that young because at this age, your body doesn't recover as fast (when you were still young)," said Pacquiao, who turns 40 on Dec. 17.
"If you keep on pushing when your body is telling you to stop, that's the time when you suffer from a burnout," said Pacquiao.
Still, Pacquiao, whose scheduled 12-rounder with Broner at the MGM Grand will be his first defense of the World Boxing Association welterweight crown, insists that he is not cutting down on the quality of his training.
"I always work hard when it is training day. I still push myself to the limit when my body tells me that I can still do more," he said, adding that his free time consists of doing cross-training, like playing high-octane basketball.
During his last training session in Manila Wednesday night, Pacquiao did the mitts with lead trainer Buboy Fernandez and was subjected to a series of plyometric exercises under strength coach Justin Fortune.
Pacquiao is now in General Santos City where he will train and celebrate his birthday before flying to the US on Dec. 22.
Fortune is going ahead to have his own gym ready in case Pacquiao opts out of the Wild Card Boxing Club in Hollywood.
"That's a Plan B," said Fortune as he raised the likelihood the training staff won't be comfortable at Roach's famous sweat shop on Vine Street.
Roach is still involved in Pacquiao's training but will have limited participation as Fernandez is taking the lead role.


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