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We have one male share spot left on our REEF Trip to Honduras in June. Join us on this great dive vacation aboard the luxurious liveaboard MV Caribbean Pearl II! Dates are June 21 - 28. We will explore Utila, Roatan, and the banks in between. This special trip is led by two marine biologists, and we hear that whale sharks could be seen! To find out more, visit http://www.REEF.org/node/8679
Other 2014 REEF trips with spaces remaining include: Hornby Island British Columbia in September, Cayman Brac in September, and Nevis in December. We have also added a trip to Fiji in May 2015 (more 2015 trips coming soon). REEF Field Survey Trips are a great introduction to fish identification for novice fishwatchers, and a fun way for experienced surveyors to build their life list while interacting with fellow fishwatchers. Prices and complete details can be found online at www.REEF.org/trips. To find out more about any of these trips or to book your space, contact our travel consultants at Caradonna at 1-877-295-7333 (REEF), email@example.com, or our staff at REEF HQ at 305-852-0030, firstname.lastname@example.com.
Need to get away before the holidays get started? Two spots are still available on the Cuan Law livaboard November 11-17, one female share and one male share. This luxurious trimaran features a wonderful menu, wide stable platform, and dive sites of various habitats sailing around the British Virgin Islands – the perfect live-aboard combo! Some of the interesting fish we will be searching for include lancer dragonets, spotted eagle rays, and striking indigo hamlets. Join REEF fish ID experts, Sue Thompson, Linda Schillinger, and trip leader Heather George for a fun-filled cruise! Details are posted online here.
If this doesn't work in your schedule, be sure to check out the full REEF Trip schedule here. Many are already full or close to it for 2013. Don't miss your chance to take a "Dive Vacation That Counts!".
REEF members are at the heart of our grassroots marine conservation programs. Over 50,000 divers, snorkelers, students, and armchair naturalists stand behind our mission.
This month we highlight Michael Murphy, a REEF surveyor in the Northeast. Mike joined REEF in 2010 and has conducted 79 surveys, mostly around his home in New Brunswick, Canada. Here's what he had to say about REEF:
When and how did you first volunteer with REEF or become a REEF member?
I have always used Andrew Martinez's Marine Life of the North Atlantic as a guide to fish and other under water sightings. It was a pleasure to meet him at Deer Island Point and talk with him about fish that we observed as well as their distinguishing features. He mentioned REEF and encouraged me to join as a way to record fish sightings. I have been a surveyor ever since! (Martinez's book is available through the REEF online store.)
What do you enjoy about being a REEF surveyor?
Being a REEF member has allowed me to participate in the Great Annual Fish Count (GAFC) each July as well as submit data year-round. I really enjoy learning about the most common fish species found in the Northeast and other dive destinations such as the Caribbean. The REEF educational webinar component, "Fishinars", is always entertaining and informative. In the future, I am hoping to use the data submitted from divers to aid in the establishment of an artificial reef and use ongoing submissions as a method of monitoring fish species. (Be sure not to miss the "Northeast Fishes" Fishinar coming up on June 13.)
Do you dive close to where you live, and if so, what is the best part about diving there?
I regularly dive at an awesome location, Deer Island Point in New Brunswick, Canada. It is about a two hour drive and free ferry trip from my home outside of Saint John. We often encounter divers from the New England States who come for the variety of organisms to be seen. It is great because there are four possible shore dives that you can enjoy, two of these are drift dives. The dives range from easy to advanced, but are subject to ties, and we can dive there year-round.
What is the most fascinating fish encounter you have experienced?
I would list as most fascinating fish encounter as being a Tuna that was swimming so fast that my dive partner missed the sighting; although seeing some Spiny Dogfish ranks a close second. My favourite fish to see is a Wolffish, they are on the endangered species list and they are so distinctive that only their mother and a hard core diver would say they are beautiful to see.
Do you have any surveying, fishwatching, or identification tips for REEF members?
I always encourage my dive partners to record their fish sighting and to submit their data. A good reference book is essential. Having the REEF Fish Identification Cards as well as a dive slate to record numbers is also important. Searching for fish, invertebrates, and plants connects me to the underwater world, which makes my diving experience that much more interesting and memorable.
Thanks to support from the SeaDoc Society (http://www.seadocsociety.org), REEF has initiated a multi-year monitoring project around the San Juan Islands in Washington State. The goal of the 10-year project is to identify changes in sub-tidal fish and invertebrate communities. The project will use recreational SCUBA divers from REEF's Pacific Advanced Assessment Team (Level 4 and 5 Expert surveyors), conducting about 100 REEF surveys each Fall. The project kicked off in September, with a team of 18 enthusiastic surveyors diving in the cold (49-degree!) but beautiful waters around the San Juan Islands. Data from this long-term project will be used by SeaDoc and other researchers over the coming years to see how well efforts to restore the Salish Sea ecosystem are working. A major mortality event among sunflower sea stars in the region was coincident with this year's monitoring effort. The team was able to provide valuable information to collaborating scientists from Cornell University and Wildlife Conservation Society on sightings of healthy and sick sea stars.
The SeaDoc Society is a program of the Wildlife Health Center at the UC Davis School of Veterinary Medicine. It was founded in 1990, and strives to find science-based solutions for marine wildlife in the Salish Sea using a multi-species approach. Dr. Joe Gaydos (see REEF Member Spotlight in this enews issue) is SeaDoc's Director and Chief Scientist. We extend a big thanks to Joe and all of the SeaDoc Society supporters for making this important long-term project possible. We also greatly appreciate the Friday Harbor Laboratory and Bandito Charters for their logistical support
In the summer of 2014, recreational divers in Florida and the Bahamas will once again assemble teams, scout out hundreds of sites, sharpen their spears, ready their nets, and hone their collecting skills to prepare for another REEF summer lionfish derby series. Six years ago, REEF began hosting lionfish derbies throughout Florida and the Caribbean to address the lionfish invasion. Not only do these events significantly reduce lionfish numbers, they also increase awareness, provide samples for research, train divers in safe removal techniques, and help develop the market for lionfish as a food fish. Teams will compete for cash prizes for the most, biggest, and smallest lionfish. Hopes are high for this summer derby series, as divers removed 2,790 lionfish in these single day events in 2013. To register or learn more, visit www.REEF.org/lionfish/derbies. 2014 derby dates and locations are: June 28 - Green Turtle Cay, Bahamas; July 19 - Fort Lauderdale, FL; August 16 - Palm Beach County, FL; September 13 - Key Largo, FL.
As the year winds down, we still have a few educational REEF Fishinars remaining. Check out the full schedule at www.REEF.org/fishinars. And keep an eye on that space because we will be adding new ones for 2015 soon. Fishinars coming up include:
Explore our Fishinar webpage, register for the sessions you like, and we'll see you online! No special software or is required - just a computer with speakers and an internet connection. And did we mention they are FREE to REEF members!
REEF's first Month of Membership Madness was a huge success! In April, lucky Michelle Rogers joined as our 60,000th member, and we far exceeded our goal, with 603 new members signing up. If you are a new member, WELCOME to REEF! The winner of the wetsuit giveaway will be announced April 15 on our Facebook page. If you haven't yet seen the video that our brilliant intern Jack Fishman produced about joining REEF, we highly recommend it (visit www.REEF.org/membershipmadness)! From being a part of the largest marine citizen science project in the world to making new fishy friends, REEF's community of members will guarantee you a fishy adventure. Also, included in this month's activities was an infographic about our incredible REEF members. This graphic illustrates an amazing diversity of support that really highlights how REEF truly depends on our members and volunteers to expand our knowledge of our underwater world. Thank you for everything!
This past summer, REEF completed its 5-year monitoring and assessment of the ex-Navy Landing Ship Dock, U.S.S. Spiegel Grove, intentionally deployed in 130' deep water as an artificial reef off Key Largo in June of 2002. At the time of its sinking, the Spiegel, at 510' in length, was the largest vessel intentionally sunk as an artificial reef. More recently, REEF completed its final report on the data collected, largely through members' efforts in the water these last few years, so a multus gratia (big thank you) from all of us at REEF to those of you who participated on the Advanced Assessment Team monitoring of the Spiegel. This was every bit your project as much as ours. I am asked quite often in the field how REEF surveyor efforts contribute to science, conservation, and education so I want to share with you some of our findings as the Spiegel assessment serves as a great example of the power of concerned and active citizen scientists to effect positive changes in our communities. For a full viewing of our final report, please visit our website at 5 Year Spiegel Grove Monitoring .
Before I highlight a few of our findings, let's go over what our methods were for conducting our Spiegel assessment. Surveys were conducted using the Roving Diver Technique (RDT), a non-point visual survey method that serves as the mainstay for most REEF efforts in the water. The purpose of this method is to gather a comprehensive species list with sighting frequency and relative abundance estimates, for fish species only in the case of this study. Staff and REEF volunteers all had to be members of the Advanced Assessment Team (AAT) for REEF (learn more about how to become an AAT member http://www.reef.org/programs/volunteersurvey/aat). Each monitoring event consisted of 4 days of two-tank monitoring dives at the Spiegel Grove and 7 surrounding reference sites.
The overall objective of the study was to assess any changes in fish community structure over time with the addition of the newly deployed artificial reef, changes not just to the Spiegel site, but changes to the surrounding natural reef sites as well. A central biological question as to the merits of vessel type artificial reef deployments is whether or not they add fish species in terms of both numbers of fish (biomass) and numbers of fish species (biodiversity) to the artificial reef and the surrounding natural reef sites. In other words, in the Field of Dreams metaphor, if you build it will they come and where will they come from? Ultimately, resource managers and other stakeholders hope that the addition of the artificial reef adds fish not only to the targeted site, but seeds surrounding reefs with the reproductive output from the resident fish population. The scale of these questions cannot be adequately addressed in a 5-year pilot study such as the one REEF just completed and that was not our charge but it is important to understand the concept behind sinking ships as artificial reefs. And we should commend Monroe County, the Upper Keys Artificial Reef Foundation (UKARF), and the Florida Keys National Marine Sanctuary (FKNMS) for funding this initial pilot study. A second socioeconomic question not addressed in REEF's work asks the important question of how much SCUBA diving pressure is decreased on natural reefs by the addition of a top recreational dive site such as the Spiegel and how much additional tourist revenue is gained? Finding answers to both the biological and economic questions above are critical in providing guidance for future marine resource management decisions on whether or not to deploy artificial reefs of this type and when and where the sinking of these large retired vessels is appropriate.
Okay, some quick highlights but again for the full report, please visit our website. Over the 5-year study, REEF conducted 76 RDT surveys on the Spiegel itself and another 445 survey dives on the surrounding 7 reference sites. 191 fish species were documented on the Spiegel Grove for all surveys combined. 46 species of fish were observed on the Spiegel just one month after deployment with the average number of species climbing to 76 per monitoring event thereafter. Approximately 3 years after deployment (Aug 2005), persistence in species composition at the Spiegel Grove site through time had increased to levels closer to those of the surrounding reefs. Striped grunts and Tomtates were immediate arrivals on the newly deployed site. Currently, 5 years post deployment, fish species composition on the Spiegel site is more akin to what you would expect on a deeper reef site including schools of Blackfin Snapper, Creole Wrasses, Bluehead Wrasses, Purple Reeffish, Sunshinefish, Bluerunners, Yellowtail Reeffish, Greenblotch Parrotfish, Tomtates, Spotfin Hogfish, Yellowmouth Grouper, Black Grouper, and the Federally protected Golilath Grouper (for a complete list of species sighted and statistical comparisons between study sites take a peak at the report). Blackcap and Fairy Basslets rarely occur in the Keys but interestingly, on several occasions, both have been surveyed on the Spiegel, most notably after hurricane storm surges from offshore. Of course, the Spiegel originally sunk on its starboard side was righted during Hurricane Dennis in July of 2005, confounding results of our survey shortly thereafter. And large, deeply sunk vessels such as this one certainly offer numerous hiding places to groupers in particular, making full visual assessments difficult. We have included in our report suggestions for future studies as well.
REEF would like to thank Mike Ryan of Horizon Divers for supplying important anectodal information about the Spiegel. He was one of the first divers on the newly deployed vessel and has logged more than 240 dives on site since then, meticulously recording fish and invertebrate sightings in the true naturalist vein. Also, REEF thanks Quiesscence Divers and Horizon Divers and Scott Fowler for providing boat and logistical support for all of our diving efforts over the past 5 years. This spring (2008), the Hoyt Vandenberg is scheduled for deployment a few miles off the coast of Key West. REEF will be leading the monitoring efforts over a similar 5-year time period and we'll keep you posted on our efforts. Two suggested readings are referenced in our report, one by Arena et al (2007) and the other by Leeworthy et al (2006) assessing biological and economic impacts of artificial reefs, respectively.
Happy Holidays everyone and if you are visiting Key Largo next year, visit the wreck and see for yourself how things are coming along.
REEF recently completed our Turks and Caicos Field Survey aboard the Aggressor II on Saturday, April 26. We had a tremendous effort by a stellar group of 20 REEF surveyors. Although we have not yet processed the data, I can give a few hints at what we saw during the week-long trip.
Overall, the group surveyed at least 213 fish species over 12 dive sites and 26 survey dives, 5 dives on most days. We surveyed many habitat types including hard and soft coral areas, patch reefs and grass beds but most of our efforts were concentrated along the famed walls along the islands. Some notable fish sightings included: Black snapper (Apsilus dentatus), Golden hamlet (Hypoplectrus gummigutta), Dwarf blenny (Starksia nanodes), Papillose blenny (Acanthemblemaria chaplini), Cardinal soldierfish (Plectrypops retrospinis), Lofty triplefin (Enneanectes altivelis), Almaco jack (Seriola rivoliana), Fringed filefish (Monacanthus ciliatus), Wall goby (Gobiosoma pallens), Black brotula (Stygnobrotula latebricola), Goldline blenny (Malacoctenus aurolineatus), and Punk blenny (Acanthemblemaria sp). We surveyed some large schools of Horse-Eye jacks and saw a number of Caribbean reef sharks. We also had two confirmed Red lionfish (Pterois volitans) sightings (see picture with article). Unfortunately, if there are two Lionfish surveyed, there are undoubtedly many more in the Turks and Caicos islands already.
We had a seasoned group of REEF members, many of whom had been on numbers of past survey trips and 60% of the group participants were expert surveyors. Consequently, our efforts were rewarded with lots of cryptic species sightings such as the ones listed above. The hospitality of the Aggressor crew was superb, gracious, and quite professional. One of the nice things about a live-aboard field survey is the camaraderie that develops between members who share a number of traits such as a love of diving, conservation-minded attitude towards our marine resources, a desire to make positive changes to said resources, and a general fish geekiness for lack of a better term, that rears it's head from time to time in visceral debates about whether someone really saw a Wall goby or not.
Fortunately for us, many members brought their cameras and we were able to verify most unusual sightings with pictures. The learning curve is leveled while on live-aboard with everyone sharing diving/surveying tips and helping each other find and verify common and rare sightings alike.
I would like to congratulate several participants on reaching new experience levels during the week: Barbara Anderson, Marty Levy, Larry Draper, and Kayla Serote all tested into level 5 surveyors. Suzanne Rose, Marie Robbins, and Kay Tiddmann are all new level 3 surveyors. Jerry Dickman is our newest level 2 surveyor. Congratulations to all the participants for a great survey effort for the week and all the good spirit shared. Also, thanks James Brook and Kristi Draper for taking Kay Tidemann under their wings and teaching her during the week, she was our most improved surveyor as a result and her enthusiasm spilled over to the group. I hope to see many of you in the water on surveys later this year. I am currently planning our 2009 Field Survey schedule and will have more details on that in our next Enews edition in May. There are still spaces available on two Field Survey trips for 2008, Paul Humann's Discovery Tour in Key Largo (June 21-28) and the Sea of Cortez with Don Jose (Oct 5-12). If interested in either of these trips, please contact Joe Cavanaugh at 305-852-0030 for the Discovery Tour and Jeanne at Baja Expeditions at 800-843-6967 for the Sea of Cortez trip.


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'The Empire Strikes Back' Day at Dodger Stadium, Jose Lima's Last Game
Monday, May 24, 2010 | 5 years ago
The Dodgers and Lucasfilm celebrated the 30th Anniversary of 'The Empire Strikes Back' on May 21 with the first 20,000 fans receiving a commemorative poster. Darth Vader, Chewbacca, R2-D2, Boba Fett, Stormtroopers and X-Wing pilots gave fans a small treat before the game, posing for photo in center field, while Chewbacca threw out the first pitch. The Dodgers beat the Detroit Tigers 4-1 during the first inter-league game of the season. Subsequently, retired Dodgers pitcher, Jose Lima, who was last seen at the game Friday evening, died May 23.
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While in a drive-in for the new Monsters University movie I decided to make Mike finger nails! This is really simple! You will need... -a blue nail a...
Roll 1-2 paper towel sheets on a flat surface
Use nail polish remover and cotton pads to take off any nail polish on your nail! Then you can apply the green and let it dry totally!
Apply a clear coat and let it dry totally! Then looking at the picture, try to make a mike coming out of the bottom corner! Then let it dry! Thanks!
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Scheme continues releasing music before his upcoming project with DJ Scend. The project is titled "Pesos Turn to Dollars" and it will be a mixture of both English and Spanish songs from Scheme. For now enjoy "Grown Man Smoke" which is a song Scheme recorded recently over production by SRNC's own The Analyst.
Expect more music and visuals in the upcoming weeks. Videos for La Clika, The Dive, Stay (Remake) and more are underway. Pesos Turn To Dollars - Coming Soon.
Scheme Grown Man Smoke (produced by The Analyst)
- Uploaded On Sep 30, 2012
- Album: Pesos Turn to Dollars
- Producer: Produced by The Analyst | Mixed by DJ Scend
- Genre: Hip-Hop/R&B
- Uploaded by: SCHEME aka NAVARRO


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Rush Limbaugh claimed that smart meters give "the government the power to wirelessly control your heat, your air conditioning, your water flow, your electricity all from the cozy central office." In fact, smart meters simply collect information on energy use for the benefit of consumers and utility companies; governments do not receive this information and have "neither the authority nor the capability to control consumers' heat, air conditioning or other in-home appliances," according to a major electric and gas utility consulted by Media Matters.
Andrew Napolitano claimed that increased oil drilling "would lower the price of gasoline tomorrow." In fact, the U.S. Department of Energy and PolitiFact agree that increased access to offshore oil drilling would not have a significant effect on gasoline prices.
Fox News figures have dismissed concerns that speculators are helping to fuel increases in the cost of oil, instead using those higher costs to push for increased oil drilling. But speculators currently hold record bets on oil futures, and experts have said those bets are driving up the cost of oil.
In at least six instances over the past three months, Fox's Eric Bolling has claimed that President Bush's July 2008 decision to lift the presidential moratorium on offshore drilling caused oil prices to drop from "$147 straight down to $33 a barrel in six months." Energy experts tell Media Matters that Bolling's analysis is wrong.
Bill O'Reilly pushed speculation that President Obama may be conspiring to keep the price of oil high in order to receive more federal revenue from "taxes at the pump." In fact, the federal fuel tax is assessed at a per-gallon rate regardless of the price at the pump.
Conservative media have promoted efforts to repeal provisions of the 2007 Energy Independence and Security Act, claiming that the law banned incandescent light bulbs and that Americans will no longer have choice over their light bulb purchases. In fact, the bill simply restricts the sale of inefficient bulbs and has lead companies to develop numerous alternatives, including energy-efficient incandescents.
Steve Forbes falsely claimed that the Environmental Protection Agency is "now regulating milk spills as part of an oil spill program," to which Fox Business host Stuart Varney replied, "That is true as a matter of fact." In fact, EPA has already said it will "exclude milk and milk product storage tanks from the spill prevention regulatory program."
A post on the conservative blog Big Peace falsely claimed that President Obama is "making us more dependent on foreign oil." However, statistics from the U.S. Energy Information Administration show that imports have declined faster than domestic production in the past several years, and current projections show that our dependence on foreign oil will continue to decrease through 2035.
From the February 26 edition of Fox News' Cavuto on Business:
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From the February 15 edition of Premiere Radio Networks' The Rush Limbaugh Show:
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From C-SPAN's February 10 coverage of CPAC 2011:
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The co-hosts of Fox & Friends and their guest, Fox Business host Stuart Varney, falsely suggested that domestic oil drilling could prevent gas prices from rising. In fact, economists and experts, including some in the Bush administration Energy Department, have admitted that offshore drilling would not substantially affect oil prices in the near future.
A February 8 post on Andrew Breitbart's blog Big Government claims that "[t]he enviros" have "succeeded with the outlawing of the lowly [incandescent] light bulb." The post also falsely suggests that consumers will be forced to buy compact flourescent lightbulbs (CFLs) instead. As Media Matters has previously documented, the incandescent light bulb will not be "outlaw[ed]" -- under the Energy Independence and Security Act of 2007, signed by then-President Bush, only inefficient models will be phased out. From the Big Government post, titled, "Who Shut Off the Lights? Bring Back the Incandescent Lightbulb":
The enviros have succeeded in destroying both the environment and jobs with their radical legislative successes. First, it was their complete stranglehold on our nation's energy policy: no new nuclear plants, a complete ban on exploring for natural gas domestically or for drilling for oil near our coasts. This forced us into the more hazardous and more expensive deep water drilling. This time they've succeeded with the outlawing of the lowly light bulb. The incandescent light bulb, the one Thomas Alva Edison invented in 1879, will be put to death in the US due to federal energy regulations. A law passed quietly in 2007 will be phased in next year with the final sales of incandescents occurring in 2014. Don't blame Obama, this was done under George W. Bush's watch.
The liberals, who always cry for "choice", don't want to give the American consumer choice in choosing light bulbs. They're apparently only pro-choice with baby killing. Otherwise, they will tell you just how to live your life, thank you. The banning of the incandescent light bulb meant that General Electric, the largest maker of light bulbs, had to close all their plants in the US. The last factory closed in Winchester, VA. in September of last year. The jobs are now all in China. They're the largest makers of the compact fluorescent bulbs, CFLs. They're not made here, in part, because they're too hazardous. [Big Government, 2/8/11]
Fox's purported business expert Eric Bolling routinely advances falsehoods about climate change, airing views and hosting guests that reinforce skeptics' claims that global warming "is just a big scam." Bolling, "once one of the biggest individual traders of oil and energy futures," also regularly pushes offshore drilling on-air.
Fox Nation today posted an article from Alex Jones' PrisonPlanet.com website, entitled "Obama's Blocking of New Power Plants Triggers Nationwide Blackouts?"
As Kate Galbraith reported yesterday in the Texas Tribune, the rolling blackouts throughout Texas earlier this week were primarily caused by problems with the power plants from the extremely cold weather -- not a government conspiracy:
Initially, it appears, some coal plants went offline due to cold-weather problems, taking a large chunk of electricity out of the grid. Luminant, a major power-generation company, confirmed that its two coal units at the Oak Grove plant in Robertson County failed, as did two units at a coal plant in Milam County. "We are in various stages of start-up and operation for that group," Allan Koenig, a Luminant spokesman, said via e-mail. Three of these four units only began operating in the last few years; Fraser, who chairs the Senate Committee on Natural Resources, noted that they had new emissions-control technologies, and said one question was how those technologies had handled the cold.
Dave Knox, a spokesman for NRG, another power company, said that a cold-weather problem also caused a shut-down of its Limestone coal plant near Jewitt, Texas. The problem occurred yesterday, albeit after the early-morning crisis, and the plant returned to operating early this morning.
Natural gas plants were hastily turned on to make up for the coal-plant failures. But, Fraser said, some power cuts affected some stations for compressing natural gas -- so without power they couldn't pump gas, causing some gas power plants to go offline. In addition, rules regarding "curtailment" of natural gas -- who gets first dibs on gas when gas supplies are tight -- were last revised in 1972, Fraser said, leaving some power plants at risk of losing out on supplies.
Fox Nation is just the latest Fox entity to mainstream Jones. Fox Business host Andrew Napolitano previously revealed himself as a 9-11 Truther on Alex Jones' radio show in November 2010. Napolitano has long been friendly with Alex Jones during his employment with Fox. Alex Jones himself is best known for his wild conspiracy theories, and was cited as an inspiration by alleged would-be assassin Byron Williams last year.


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Album Rating: 3.5But it's also so true.
Album Rating: 2.5Nice review.
Album Rating: 2.5It isn't
ET is though
agreed used to sing it with my short pakistani friend oh how i miss him
Digging: Self Defense Family - Heaven Is Earth
nah, it's all about E.T
Digging: Bosse-de-Nage - All Fours
i was agreeing with cyg fuck u guys
actually ET is good too tho
Album Rating: 2.5damn choccy mindreader
also et and tgif are pretty good too tbh, but maybe it's bc i associate them w/ friends
and good timez...
also as long as et doesn't have kanye, love the man but goddamn way to completely ruin a possibly good
That and maybe Last Friday Night.
The version of E.T without Kanye West is pretty good though
lol ok, that was an odd coincidence ^
^too many, my friend
yeah fuck this has all the best katy perry songs
Album Rating: 2.5ET is better without Kanye
EDIT: Again, Choccy...
Album Rating: 3.5"why is t/t so fucking perfect??"
this has what, 1-2 good songs and 1 almost perfect one?
better than most out there.
I think it's more the good songs and bad moments are universal.
But seriously, when Kanye says "what's next, alien sex?"
or some crap like that
Album Rating: 2.5best katy
definitely, she's had like -10 good hits since this album came out and maybe 2 before it
Album Rating: 2.5the new album is abysmal
Bands: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


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What happened?
"Surprisingly, Americans only consume 100 calories a day more than during the 60's, however due to the sedentary nature of employment, long commutes and sedentary nature of home recreation (eg 500 cable channels) we now burn 600-700 calories less per day. That equates to more than a pound of potential weight gain per work week," noted Bordley.
TrekDesk reverses the trend immediately and allows an individual to burn between 800-1400 calories per day, equating to 1-2 pounds of body fat loss per week.
"Our health is in our hands not the health insurance industry's," states Bordley, " the National Institute of Health states that 84% of all medical claims are the direct result of poor diet, lifestyle and an extreme lack of exercise. TrekDesk can make the exercise easy and automatic without any additional time commitment, that is why it is getting so much attention in the corporate and home office marketplace."
The Scottsdale Civic Center Gallery Technology Fair runs this Saturday from noon to 5 PM at 3839 Drinkwater Boulevard, Scottsdale, AZ.
Steve Bordley
Ph: 877-449-8588
info (at) trekdesk (dot) com
Read the full story at http://www.prweb.com/releases/treadmill_desk/TrekDesk/prweb3298674.htm.
|Source: PRWeb
Copyright©2009 Vocus, Inc.
All rights reserved


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- Rays beat Nationals 5-3 as Harper leaves game Updated: Jun-19-15 12:35 am
WASHINGTON - While the crowd at Nationals Park was worried about the home team's star slugger Thursday night, the Tampa Bay Rays left town with a two-game sweep.
- Nationals OF Harper strains hamstring, exits in loss to Rays Updated: Jun-18-15 10:55 pm
WASHINGTON - Nationals star Bryce Harper strained his left hamstring while taking an awkward tumble making a throw, and Washington lost to the Tampa Bay Rays 5-3 on Thursday night.
- Pujols, Trout homer in Angels' 6-2 win Updated: Jun-12-15 12:17 am
ST. PETERSBURG, Florida - Albert Pujols' home runs these days come with a baseball history lesson.
- Kevin Kiermaier's 10th-inning HR helps Rays beat Angels 6-5 Updated: Jun-04-15 3:09 am
ANAHEIM, California - Kevin Kiermaier took early batting practice even though he wasn't in the starting lineup, and it came in handy when he entered as a defensive replacement.


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Talk about a beautiful friendship. In 2011, Clarins and FEED joined forces and rolled out limited-edition signature makeup and tote bags, chock-full of Clarins' top-selling skin-care products, to department and specialty stores. Depending on their contents and size, the bags provided between 10 and 25 school meals to hungry children worldwide. This year, the partners upped their efforts and staged the Clarins Million Meals Concert for FEED at Lincoln Center's Alice Tully Hall. The event—featuring performances by John Legend, Natasha Bedingfield and special guest Bill Clinton—generated one million meals in one night. "The dream is that no child in the world is without food," said Christian Courtin-Clarins, chairman of Groupe Clarins, who in May traveled with FEED cofounder Lauren Bush Lauren to Honduras to see the organization's work firsthand. In the last 12 months, Clarins and Feed have already reached their original goal of raising one million meals over the course of two years; their intent now is to double it. Said Courtin-Clarins, "We make a living by what we get, we make a life by what we give."


text:
- Course: Main Course
- Total Time: Under 2 Hours
- Skill Level: Moderate
- Cost: Moderate
- Favorited: 11 Times
Photo by: Joey De Leo
© Christopher Idone
Yield: Serves 6
- ¼ pound unsalted butter
- 1 small yellow onion, finely chopped
- 2 celery ribs, finely chopped
- 2 cups crumbled corn bread
- 1 teaspoon finely chopped fresh sage
- 1/2 teaspoon chopped fresh thyme
- 1/2 teaspoon chopped fresh rosemary
- ¼ cup heavy cream
- 1 dozen oysters, shucked and drained with about 1/2 cup oyster liquor reserved
- 1 egg
- Salt and freshly milled black pepper
- 2 whole chickens (each about 3 1/2 pounds)
Preheat the oven to 450° F.
In a medium skillet, melt the butter and sauté the onions and celery until wilted. Turn into a bowl and add the remaining stuffing ingredients.
Stuff and truss the chickens and set them on a rack in a large roasting pan. Roast for 1 hour to 1 hour and 20 minutes, or until the thigh juices run clear, basting from time to time. Allow to rest for 10 minutes before serving.
© Christopher Idone
Nutritional Information
Nutrients per serving (% daily value)
Nutritional information is based on 1/8 teaspoon added salt per serving.
1408kcal (70%)
170mg (17%)
11mg (19%)
401mcg RAE (13%)
500mg (167%)
930mg (39%)
35g (177%)
101g (156%)
7mg (41%)
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2004 Chevrolet Suburban 1500 Q&A
2004 Chevrolet Suburban 1500 Question: Transmission slipping with traction control ON, but not OFF.
I was experiencing what felt to be transmission slipping when the truck would shift from 1st to 2nd at slow speeds. I had the trany fluid changed, but it no more than regular wear as far as metal. When the problem occurs, the traction control activates... because of that, I tried turning the traction control/stability control off... with that OFF, the problem has completely stopped... any help out there for what may be the problem? THANKS INADVANCE! - hemini
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15 things we can't wait to do at camp
Is he flirting with you or just a friendly dude?
Meet Quasi Modo, the secretly adorable winner of the Worlds Ugliest Dog contest
Laura Marano gave the most WONDERful performance at this summer camp
Love is in the air, Aquarius!
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Girls on social media demonstrate #thepowerofmakeup to be empowering
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Hey all you Jake Short fans - check out his 30 day photo challenge from Olivia Osteen on Facebook and Instagram.
Awesome Stuff!!!
by Dixie7 on 2/1/2013 6:34:35 PM
Hey girls! Looking for advice on school and friends? Need someone to listen to you vent? I'm here! If you want advice or just someone to listen to you, feel free to post a comment to my profile or visit my Advice Queen page! Have a great day
by ohheyitsjennyy on 10/7/2012 9:56:37 PM
this picture is sweet and kind and cool that there helping kids
by Magskelly on 9/19/2012 3:13:25 PM
that is so sweet and kind
by Magskelly on 9/19/2012 3:12:20 PM
Lol I didn't even notice jake short until I read he was in the picture
by Abbydabbers on 9/2/2012 9:52:55 PM
Hey gals! Join Just the girls! It's a club where we talk about everything girl related: sports, health, makeup, hair, shopping, hobbies, GUYS, and EVERYTHING ELSE!!! Positions still open! Plz join!
by cousin11 on 8/27/2012 8:27:22 PM
by ShyKA on 8/27/2012 6:26:35 PM
by superglittergirl on 8/27/2012 4:32:21 PM
by cloudyday on 8/27/2012 2:00:27 PM
One way I plan on helping out around town this school year is by volunteering to help with community service opportunities at my school.
by otter77 on 8/27/2012 1:37:28 PM
I would definitely stop obesity! Though 'm under-weighted and people always ALWAYS tell me to stop worrying about others and more of me, I can't stop, I would make helpy snacks for different clubs in our school which will cause for students to lose weight and also tell my gym teacher to try and do some work-out which will make people burn more calories in 45min that we have in P.E.
by Susmita24 on 8/27/2012 1:03:22 PM
by pretty123 on 8/27/2012 1:00:14 PM
I'm probably gonna donate blood. I've never done that before! Also I love going to the Humane Society and helping all those adorable animals! Lastly, I want to do something to help Haiti. They got hit with an earthquake in 2010 and now Hurricane Issac! I really want to help them in some way.
by turnonthemusic1 on 8/27/2012 12:32:29 PM


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If quantity is 1, do you actually receive 4 chairs? All 4 in the selected color?
NPS Fabric Upholstered Premium Folding Chairs (Pack of 4)
Update your furniture collection with this premium fabric folding chairs in a pack of four. These convenient folding chairs feature a one-inch fabric upholstery on the back and seat for comfort, while matching any decor with its six color options.
ITEM#: 12584211These comfortable folding chairs feature fabric upholstery on the seat and the back. Available in six color options, these chairs are sure to match any decor. The double contoured back on these attractive chairs ensures comfort that lasts through extensive use. Each set includes four chairs for you to add to a table you already own, or shop around for a new table to match your color choice. These chairs fold up and store away out of sight for times when you need to quickly add extra seats or make extra space, such as family gatherings.
The chairs are equipped with non-marring glides, so they're easy to set up or fold, and you don't have to worry about the parts rubbing against each other. The seats and backs of the chairs are firmly riveted to the frame for safety and stability. These versatile chairs are great for expanding your seating options at home or work.
- Color options: Cafe beige, greystone, imperial blue/char-blue, imperial blue/grey, russet walnut, majectic cabernet
- Fabric upholstery
- Seats and backs are securely riveted to the chair so that they don't loosen and fall off
- The 1-inch upholstery covers the entire seat and back
- Double contoured back
- Double hinges
- Two double-riveted U-shaped cross braces
- Non-marring glides
- V-tip stability caps
- Set includes four (4) chairs
- Each chair measures 29.5 inches high x 18.75 inches wide x 20.25 inches deep
|Beige Black Blue Brown Grey
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Perfect set of chairs. Well made and sturdy.Read More
Just what I needed to expand our Tuesday night Bible study around our dining room table. Very sturdy and comfortable. The scotch guard is a plus. Price was great. Would buy again.Read More
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We don't fight anymore over who has to sit in the "extra" chair, because these are so comfortable. They came already put together and store in just a wee bit of space.Read More
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You guys at Overstock rock! These chairs are just what I wanted and needed for additonal seating for Thanksgiving. I thought to my self, "What if they don't get here in time?" Well, I ordered on Wednesday afternoon and they were delivered on Thursday afternoon. I couldn't believe they got here so fast! Even the rental place couldn't have gotten them here that fast. They are sturdy, and the upholstery on the seats and backs will be so nice and comfortable for my holiday guests. I ordered 2 sets of 4, and I will probably order another set. We entertain a lot and they will be used for many years to come. Thanks Overstock!Read More
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These chairs, while well made, would not be comfortable to sit in for any length of time because the sitting seat is not deep enough to support the back of the legs. I am an average size person, and the chair is not comfortable to me.
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The annotated tag, v2.4.9_007 has been created
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tagging 68e92867ef55db36bd7255b5008d0b50652097d1 (commit)
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Asian American Pacific Islander (AAPI) Heritage Month each May is a time to celebrate, reflect on and pay homage to the many generations of Asian Americans and Pacific Islanders who contributed their talents to America's history. They came here with hopes of getting a slice of the American pie, such as starting a business or securing a good job, and having the financial resources to raise a family and enjoy a comfortable retirement. For some older members of the AAPI …
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Workers 50 and older face a hurdle that younger peers don't: how to overcome negative stereotypes that paint them as much more expensive, out of touch with technology and less productive. An AARP report released Monday dispels these myths. The report, "A Business Case for Workers Age 50+: A Look at the Value of Experience 2015," was conducted by Aon Hewitt and based primarily on data from large employers. A similar report, which confirmed the value of older employees, was done …
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For decades, the three-legged stool was the metaphor for funding retirement: Social Security, pensions and savings/investments. Because of the recession and drop in pensions, the stool started to shake. That hasn't escaped the notice of our adult children as they watch parents head into retirement. The upside of those watchful eyes is that many millennials have begun saving for their own retirement. At an unprecedented age of 22, some 70 percent of working millennials are socking money away, according to …
Posted: 04/14/2015 by Eileen Ambrose | Comments
Financial advisers would have to adhere to more stringent standards when giving advice on 401(k) plans, IRAs and other retirement accounts under a rule proposed Tuesday by the U.S. Department of Labor. The proposed rule would protect people saving for retirement from being steered into accounts with high fees and commissions that benefit the adviser at the expense of the saver. It would force financial professionals to act in the best interest of their clients — a move that advocates say would …
Posted: 02/24/2015 by Eileen Ambrose | Comments
El presidente Barack Obama pidió al Departamento del Trabajo (en inglés) federal que presente una normativa para proteger los ahorros de las cuentas IRA, 401(k) y otros planes de jubilación ofrecidos por los empleadores, de cargos y gastos ocultos que pueden representar pérdidas de miles de millones de dólares a los ahorristas. El presidente quiere que a los corredores de inversiones y otros asesores se les requiera actuar teniendo en mente el mejor interés de los inversores y no el …
Posted: 02/23/2015 by Eileen Ambrose | Comments
President Barack Obama called on the Department of Labor today to draw up a rule to protect people who save in IRAs, 401(k)s and other workplace retirement plans from hidden fees and expenses that may drain billions from their accounts. The president wants brokers and other professionals to be required to act in an investor's best interest — instead of their own — when dispensing advice on retirement accounts. "Right now there are no uniform rules of the road that require retirement advisers to …
AARP is a nonprofit, nonpartisan organization that helps people 50 and older improve the quality of their lives.


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44 year old woman | Gibsonville, NC, USA | Seeking men 38-48 within 20 miles of Burlington, NC
But this one goes to 11....
I am on the market and cautiously looking, but I am open to the possiblilites. I am looking for someone to go out and share dinner and conversation with. First impressions are important, but I also believe chemistry develops as you get to know someone. I crave that giddy school girl feeling! You must have a sharp, sometimes irreverent dry wit, be somewhat intellectual but not arrogant. Useless pop trivia knowledge is a plus! I am looking for a nice guy but not a good ole boy. I love a man with a dynamic personality, but who also has the ability to show some vulnerability at some point. I am impressed by good manners and common courtesies. I don't play games and don't care for men who do. It's important that you have something you are passionate about! I like to be intrigued by a man. My celebrity crush is ABC White House correspondant Jake Tapper... yeah I'm weird like that. I am looking for my intellectual equal but also someone who can bring out my inner 12 year old. She's a fun girl! I love live music and doing something outdoors but I am just as happy sitting on the couch watching a movie and canoddling. Sometimes being a little lazy is just what I need! I don't like to take some things too seriously, life should be fun and I will always try something once. I am a mom to 3 extraordinary kids and love spending time with them. Having someone who has children and understands all the joy (and stress) that comes with that is very important to me. If you are looking for a woman who is always put together, always has perfect hair and makeup I may not be the girl for you. I think I look great for my age and although I am not in the best shape of my life (single mom of 3 doesn't give me much time for the gym anymore :( ) I feel more confident about my looks than ever. Curvy just means I have real hips and boobs if you're into that. In my former life as a stay at home mom I performed standup comedy a few times a week... before I had to work for a living (boo!). So if you can make me laugh, I'm putty. I tend not to kiss on a first date unless of course you see hearts radiating from my eyes by the end of the date. One last thing, if you are wearing sunglasses in your profile picture (yawn) or mean-mugging for the camera (hint:women like men who smile)...please let me help you revamp your profile.
Coffee and conversation , Cooking , Dining out , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Nightclubs/Dancing , Performing arts , Shopping/Antiques , Travel/Sightseeing , Volunteering
Dancing, Other types of exercise, Skiing, Walking / Hiking, Weights / Machines, Yoga
I exercise 1-2 times per week.
I like Cats, Dogs
I have a Tomcat who is self-sufficient and a goldfish that has survived amazingly.
New York City; Boston; DC, Charlotte, Asheville
The University of North Carolina at Charlotte, Charlotte, NC
Rolling Stones, The Who, AC/DC, Johnny Cash, Steely Dan, Documentaries, 60 minutes, CBS Sunday Morning, 48 hours, The Office, Celebrity Ghost stories, David Sedaris Books, college basketball, food, SWEET tea! and quality time with my kids
Read memoirs (Augusten Borroughs-David Sedaris); watch television (lo brow and hi brow programming). Go to the movies (LOVE the coming attractions!), love to eat (don't let the small frame fool you I eat like a trucker) esp Thai. Biking and Hiking.
The Good Earth, rereading Naked by David Sedaris
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What she is looking for
|5'2" (157cms)
|5'9" (175cms) to 6'4" (193cms)
|Body type:
|No preference
|No preference
|Dark blonde
|No preference
|No Way
|No Way
|Social Drinker
|Social Drinker
|Sales / Marketing
|No preference
|I'll tell you later
|No preference
|No preference
|Have kids:
|Yes, and they sometimes live at home (3)
|Yes, and they sometimes live at home, Yes, and they live away from home, Yes, and they live at home
|Wants kids:
|Probably not
|Not sure, Probably not, No, No, but it's OK if my partner has kids
|White / Caucasian
|White / Caucasian
Scotch-Irish and proud of it!
|Spiritual but not religious
|No preference
No Atheists or Fundamentalists. Have you seen Religulous?
|Bachelors degree
|Some college, Bachelors degree
BS in Criminal Justice


text:
Deviant Art
NaruHina ValentinesNaruHina Valentines8 years ago in General More Like This
NaruHina Valentines
Naruto sat on the swing in the academy hanging on the tree. He watched as everyone in his class gave valentines to their peers. He sighed and kicked the pebbles on the ground that were by his feet.
"Valentines Day again....."
He never got any valentines so he was used to it.
"I wish this day was never even made. I mean, who cares about love anyway...."
Naruto watched as all the girls went after Sasuke with their chocolates and stuff.
"Stupid Sasuke....and your stupid attitude..."
Naruto wished that all the girls chase him instead of Sasuke. One girl caught his eye though. She was the only one not after Sasuke. Her hair was a navy color and her eyes were white with a shade of lavender. He remembered that she was the Hyuuga heiress, Hinata.
"Whats up with her...? I thought all the girls would be after him...."
She just sat on the bench with a valentine next to her.
"Such a weird girl....."
Iruka called them to come back to class. Naruto got off the swing and started t
Sayuri Uzumaki's storySayuri Uzumaki's story7 years ago in Fan Fiction More Like This
You know how Hinata had grown a evil side
You all know of how Naruto and Hinata got together
How Hinata gets pregnant on a first date ..
And how theyre baby was born .and had red eyes .
And youve asked .why?
Well, lets see how does Sayuris story go again?
Ah, its goes something like this .
Gosh darn you!!! Quit being like your father!!!
The said trouble-maker smirked. She continued running. As she neared the park she stopped.
Hmmm . Where are you
All of a sudden someone popped up and kissed her. As they let go, the boy smirked.
Gotcha Sayuri
You cheated you devil
Thats what they call me
Sayuri Uzumaki? Yes.
It was 16 years since Hinata had given birth to her. She was a beautiful young woman that people loved. The only thing was her a
|Sta.sh Submit


text:
Meeting The Fluid Management Conditions of Coverage Thru Crit-Line Monitor Use TODAY'S PRESENTER Diana Hlebovy RN, BSN, CHN, CNN Director of Clinical Affairs Hema Metrics Objectives • Discuss the rationale for adding fluid management into the Conditions of Coverage (CfC) • Review the long-term complications of HD related to FVE and FVD • State the conditions and interpretive guidelines related to fluid management • Verbalize the CLM as the Gold Standard of fluid management to meet the CfC Conditions of Coverage: Community Comments • Volume mismanagement is the main cause for cardiac related morbidity and mortality rates • Not referring to it was a "Serious Omission" that needed to be corrected. • Fluid management cited as the current "Orphan in Quality Assessment". • It is the "Single Most important indicator" related to morbidity and mortality • Without managing volume and its effects on the heart, there would be no patients. Conditions of Coverage 494.80 Patients must be assessed for the appropriateness of the dialysis prescription, blood pressure and fluid management at §494.80(a)(2), which encompasses intradialytic symptoms and issues, such as cramping, as well as dialysis adequacy. Conditions of Coverage: Community Comments • CMS received several comments regarding §494.90(a)(1), "Dose of dialysis." • Some commenters suggested we include patient volume status ( measurement of body fluid removal) in the adequacy requirement Conditions of Coverage: Community Comments • Kt/V levels did not correlate with mortality or morbidity • Dialysis adequacy monitoring needs to be modified to require facilities to "monitor fluid status." • Better methods of measuring intravascular volume and related blood pressure changes are needed Conditions of Coverage 494.90 • Volume control, important to blood pressure management and cardiac health, is an essential component of dialysis care that requires ongoing attention from the care team. • Therefore, we are incorporating it into the "dose of dialysis" plan of care element. • Under the "Patient plan of care" condition, we have modified §494.90(a)(1) to read, "The interdisciplinary team must provide the necessary care and services to manage the patient's volume status" "Protect the Pump " The principal goal of these conditions is to improve cardiovascular outcomes by optimizing fluid management practices and strategies during hemodialysis "Protect the Pump " Fluid Management is a - High Risk - High Volume - Problem Prone - High Cost Aspect of Care that must be clearly included in the Quality Assessment and Performance Improvement Plan (QAPI) "Protect the Pump" Optimal Fluid Management strategies need to be implemented to provide: The right care for every person, every treatment, every time Fluid management Strategies need to be: • Safe • Effective • Efficient • Patient-centered / Individualized care • Timely • Equitable "Protect the Pump" Current Trends Current Trend :Safe Occurrence of Intradialytic Morbidities (Ischemic events) during HD : • Hypotension up to 50% • Hypoxemia 50% • Cramping 20% • Nausea/ vomiting 15% • Seizures up to 10% • Angina 5% • Myocardial Ischemia 22% TXs • Dysrhythmias 50% of patients • Cardiac arrest 7/100,000 TX • Sudden death 25% of all deaths in HD population Effects of Intradialytic Hypotension • Tissue Ischemia / Hypoxia • Adenosine release causing decrease in PVR • Changes in Mental status / Seizures / Stroke • Vision changes • Silent cardiac ischemia / MI • Ischemia / Infarct to the gut • Decrease in Residual Renal Function • Ischemia = decrease in URR "Protect the Pump" Change concepts: Medical injuries and medical errors: V634(vi) " Occurrences such as treatment prescription errors, intradialytic morbidities (IDMs) ….should be identified, reviewed and trended. "Intradialytic morbidities" is any adverse symptom that occurs during the dialysis treatment to include but not be limited to seizures, chest pain, hypotension and cardiac arrest. V640 : Patient Safety The facility must immediately correct any identified problems that threaten the health and safety of patients. Current Trend: Effective • Mortality rate remains >20% • Average ESRD Treatment Life is 62 months • CVD accounts for 50% • >90% of patients are hypertensive • 70% have Left Ventricular hypertrophy • CHF was found in 40% of ESRD patients • 60% remain in fluid volume excess post TX • Two or more hypotensive episodes per week increase the death rate by 70% • Residual Kidney function decreases with IDMs • Hemoglobin "Time in range" remains difficult to maintain "Protect the Pump" Change concepts: • Hemodialysis is a remarkable cardiac stressor • Critical thinking needs to be put back into Dialysis • Treatment records must reflect attaining target weight (V543 Dose of Dialysis) Current Trend: Efficient • Average BP meds 3 ( 5 not uncommon) • CVD is a major cause of hospital admissions for patients on hemodialysis, accounting for 49% of chronic and 40% of acute admissions • Pulmonary edema being the most common admitting diagnosis • Extra treatments for Fluid removal - UF only continue • IDMs are considered an acceptable/ expected side effect • Recovery time following typical HD is >1 day The Dry Weight Issue Prevalence of Patients on Antihypertensives 1970 10% 1997 75% 2002 80-90% Cary, 2002 "Protect the Pump" Change concepts: V543 Dose of Dialysis The ultrafiltration component of the hemodialysis prescription should be optimized with a goal to render the patient euvolemic and normotensive. A patient at their EDW attains normotension for most of the interdialytic period, while avoiding orthostatic hypotension or postural symptoms either during or after dialysis. With successful fluid management, the number of medications a patient needs for blood pressure control may be able to be reduced. Quotes from Dr Charra • "Need to Focus on Dry Weight" • "Dropped the Ball with failure to Achieve and maintenance Dry Weights" • "Control of Dry Weight = Control BP = Increase in Survival Rate" Current Trend: Patient Centered • UF Goal set by comparing pre-weight to EDW • EDW generally incorrect • UFRs exceed recommended 10ml/kg/ hr • Plasma refill rates are different on different days depending on numerous patient variables • UF Profiles are not individualized for each TX • Standard 2 gram sodium diet still prevalent • Facility Standard Dialysis bath / temperature • Sodium modeling remains on the majority of patients To avoid thirst, fluid gains and hypertension, the NKF-KDOQI Clinical Practice Guidelines state that increasing positive sodium balance by "sodium profiling" or using a high dialysate sodium concentration should be avoided. "Protect the Pump" Change concepts: 494.80 Condition: Patient assessment: V503: : Appropriateness of Dialysis Prescription • The patient record should show evidence that the patient's individual dialysis needs have been assessed and the current dialysis prescription evaluated as to whether it is meeting those needs. • "Individualized" means each assessment is unique to a particular patient and addresses that patient's needs(V501) Current Trend: Patient Centered • Oxygen needs are rarely assessed • Root causes for IDMs rarely assessed • TX of IDMs consist of stopping UFR/ Normal saline/ Position change • Staff feel they are doing "all they can do" • Patients are labeled "noncompliant" if fluid gains are excessive • Patients are blamed for the cause of crashing • Staff/ Patients believe that if they "crash" they have reached their EDW Three Compartment Model Fluid Shifts Intra- cellular Space Extra- Circulating cellular Blood Volume Space Intra- 2Vascular Dialyzer Toxins Space Toxins Toxins Fluid Fluid Fluid 23 Liters 17 Liters 5 Liters Dialysis Assessment Just because a patient "Crashes" It does NOT Mean they are "DRY"!!! "Protect the Pump " Change concepts: • It is unacceptable for a patient to feel bad during or after the hemodialysis related to the dialysis process • Efforts to improve the patients experience while receiving hemodialysis services need to be promoted • Hemodialysis (HD) treatments need to be personalized and individualized: no cookie cutter dialysis! V559: Adjusting the plan of care This requirement is not met/ not satisfied if: • The patient's plan of care is not adjusted / individualized • There is no evidence the IDT is working to address ongoing problems (e.g., uncontrolled hypertension, hyperkalemia, missed treatments, inaccurate or unattainable target weight • The only reason documented for failure to achieve goal(s) is "patient non-compliance" or "non- adherence." Current Trend: Timely • Treatment of IDMs are reactive vs. proactive • EDW is changed after event or admission for CHF • UFR generally exceed plasma refill rate causing IDMs • Number one cause of getting off early / skipping TX is IDMs or fear of them Current Trend: Equitable • Hospital days remain high: - 2 admissions; 14 days per patient per year - CV causes are increasing by 10% - Time in range effects the Relative Risk • Extra normal saline, hypertonic, mannitol. Albumin, oral medications given for treatment and prevention on IDMs • Patient are still receiving extra treatments for fluid removal • Medicare budget is significantly impacted "Protect the Pump " Change concepts:). V520 Standard: Patient reassessment Monthly reassessment of unstable patients which includes inadequate dialysis Inadequate dialysis also include symptoms related to fluid management such as: •Volume overload or depletion •Intradialytic symptoms such as syncope or congestive heart failure •Hypotension •Hypertension •Need for extra treatment for fluid removal •Sudden onset of cardiac arrhythmias "Protect the Pump " Change Concepts: • The goal of ultrafiltration is to obtain normovolemia and normotension without Intradialytic morbidities (IDMs). • This along with solute clearances comprises adequacy of dialysis V543: Dose of dialysis Defines EDW- and the inter/ intradialytic measures that will be used to evaluate the outcomes: • A patient at their EDW should be: - asymptomatic and - normotensive - on minimum blood pressure medications - while preserving organ perfusion and - maintaining existing residual renal function "Protect the Pump" Clinical Performance Measures (CPMs) for fluid management ( attaining Dry Weight) may include: • Pre/ Post/ lowest BP • Number of BP medications • Hospitalizations related to fluid management • Intra/ interdialytic morbidities • Cardiac arrest, sudden death • Reassessment of residual kidney function (RKF) • Dry Weight (plasma refill) checks if BVM available QAPI: Measurement Assessment Tool (MAT) • V543 Dose of Dialysis: Management of volume status • Value monitored: Euvolemic and Normotensive - BP 130/80 (adult) - Lower of 90% of normal for age/ht/wt or 130/80 (pediatric) Learning from "history" • Clyde Shields • First long-term HD patient in the US, March 1960 • Developed malignant HTN within a few months • Treatment: aggressive ultrafiltration (UF) • Three times per week HD – 8-10 hours each • Result: 11 years of dialysis in the 1960s • "The key to treating HTN in dialysis patients is adequate control of the extracellular volume". AJKD;6:511-519,1990 Scribner BH: The new conditions of coverage also elevate the importance of fluid management effects on: • Anemia (V507; V547) • Nutritional status(V509; V545) • Access patency(V 551) 494.140 Condition: Personnel qualifications.V681 Staff education is now mandated to include specific competencies such as : • Identifying and treating intradialytic morbidities • Monitoring patients • Equipment alarms Crit-Line Monitor: The Gold Standard of Optimal Fluid Management Crit-Line's Clinical Impact in Fluid Management Clinical Studies compiled over 5 years have documented: 70% Reduction in Intradialytic Morbidity (i.e. "CRASHING") 50% Reduction in Anti-hypertensive medications 48% Reduction in Hospitalizations due to Fluid Overload > 45% Reduction in Hospitalizations due to Access Complications (See Howard, et al.) 55% Reduction in Left Ventricular Hypertrophy Meeting the new Conditions of Coverage with the Crit-Line Monitor (CLM): Protect the Pump CLM IMPACTS: Hypotension, Hypertension, CHF, Myocardial Infarction, Organ Ischemia Stroke, Sudden Death Quality of Life Costs Financial Costs Quality of Life Costs Financial Costs Patient Recovery Time, AMA's, Hospitalizations/Hospital Days Rehabilitation Potential Medications/IV Solutions to TX SX Medications to TX Hypertnesion OUTCOME MEASURES BP's (Hi/Low/Medications), Dry Weight/ECV/TBW, Residual Renal Function, Inter/Intradialytic Symptoms, Sudden Death, Left Ventricular Mass Index (Echo), Hospitalizations/Morbidity/mortality/Economics/QOL, Hemoglobin Variability End – Section 1 Thank you for taking time to learn about the new CMS Conditions of Coverage as they relate to fluid management. To learn how the Crit- Line Monitor can help you meet these new conditions, please select Section 2 of this presentation. Additional Information • Please call 1-800-546-5463 if you would like additional information or would be interested in evaluating Crit-Line at your clinic • Additional information can also be found at www.hemametrics.com Section 2 Crit-Line Monitor a tool for compliance with Conditions of Coverage. Thank you for taking time to learn about the new CMS Conditions of Coverage as they relate to fluid management. In this section, you will learn how the Crit-Line Monitor can help you comply with these new conditions. Multi-parameter Platform FDA 510k Approved CRIT-LINE Parameters Blood Flow • Hematocrit (HCT) Blood Chamber • O2 Saturation (SAT) • Change in Blood Volume ( BV) Emitter Detecto r Fundamental Parameter: Hematocrit (Hct) Test tube represents circulating blood volume Plasma Volume Total Blood RCV Volume (BV) Hct = BV Red Cell Volume (RCV) HEMATOCRIT RCV (Test tube represents HCT = circulating blood volume) BV Total Blood Volume (BV) Red Cell Volume (RCV) Hematocrit and Blood Volume 35 33 Hct 31 29 RCV 27 0 Hct = X 100 BV %BV (Loss) -5 -10 -15 -20 -25 0 1 2 3 4 HYPOXEMIA DURING HEMODIALYSIS TISSUE ISCHEMIA TISSUE ISCHEMIA TISSUE ISCHEMIA Releases adenosine Releases adenosine Blocks the release of Blocks the release of . norepinephrine norepinephrine from from This tissue This tissue ischemia effect ischemia effect maybe the reason sympathetic sympathetic nerve nerve maybe the reason that anemic that anemic terminals terminals patients are prone patients are prone to hypotension. to hypotension. Types of Hypoxia: Causes in ESRD • Hypoxemic Hypoxia Fluid excess COPD; ↓CO2 Sleep Apnea • Anemic Hypoxia Anemia (Hgb ≤ 10) • Circulatory Hypoxia Cardiac Dysfunction, arteriosclerosis Factors to Consider: Source Arterial Blood: Internal Access ( Fistula /Graft) • Mixed Venous Blood: CVC line • 90 to 100% is considered normal for arterial sats (SaO2) • 60 to 80% for mixed venous sats (SvO2) Complimentary Oxygen Delivery Issues 02 Delivery 20+ % of HD patients have intradialytic hypoxemia and up to 70% are sleep apneics. Sleep Apnea Profile 95 Oxygen Saturation 90 85 Sleep 80 0 1 2 3 4 Time (hours) Access: Catheter SvO2 Venous Blood Lower O2 Saturation Factors to Consider: Source The continuous monitoring of SvO2 is a sensitive Parameter of continuous Cardiac Output C. O. = Heart Rate x Stroke Volume Seizure 1 hour 55 min into TX The Guyton Curve 8 Edema 7 Blood Volume (liters) 6 Normal 5 4 3 Death 2 1 Adapted from Guyton, AC: Textbook of Medical Physiology, 1991, pg.324 0 0 5 10 15 20 25 30 35 40 Extracellular Fluid Volume (liters) Three Compartment Model Fluid Shifts Intra- cellular Space Extra- Circulating cellular Blood Volume Space Intra- 2Vascular Dialyzer Toxins Space Toxins Toxins Fluid Fluid Fluid 23 Liters 17 Liters 5 Liters 8 Blood Volume (liters) Edema 7 A 6 5 Normal 4 3 Death 2 Adapted from Guyton, AC: 1 Textbook of Medical Physiology, 1991, pg.324 0 0 5 10 15 20 25 30 35 40 Extracellular Fluid Volume (liters) 5 0 BV -10 -20 TIME 03:25 HCT 31.2 BV 0.2 SAT 98 5 0 -10 -20 1 2 3 4 5 Time (hr) 8 Blood Volume (liters) 7 6 B 5 Normal 4 3 Death 2 1 Adapted from Guyton, AC: Textbook of Medical Physiology, 1991, pg.324 0 0 5 10 15 20 25 30 35 40 Extracellular Fluid Volume (liters) 5 0 BV -10 -20 TIME 03:25 HCT 34.7 BV -17.3 SAT 94 V543 Dose of Dialysis Evidence of implementation of the plan of care for this aspect would include: • Treatment records reflecting attaining the target weight at the end of each treatment or • Documentation acknowledging the target weight was not attained with an assessment of the reason for not attaining it, and a plan to correct this issue. Blood Volume Monitoring and Post Dialysis Vascular Refill( Dry Weight Check) in 3 Different Patients. Arrows show end of ultrafiltration BV reduction: 16% No Vascular Refill BV reduction: 12% Vascular Refill Hours BV reduction: 6% SLT Vascular Refill Hours Rodriguez et al Kidney Int 68:854,2005 Rodriguez Summary When used in combination with clinical assessment, the Crit-Line monitor results in: • Optimization of Extracellular fluid status • Reductions of intra and post dialysis morbid complications • Improvements in patient well-being • Potential reductions in hospitalization due to fluid overload "Provides an objective way of assigning Dry Weight" V504: Blood Pressure and Fluid Management Needs ..."blood volume monitoring during hemodialysis should be available in order to evaluate body weight changes for gains in muscle weight vs. fluid overload". - Mandated for pediatric patients - Imperative for adult patients V504: Blood Pressure and Fluid Management Needs The comprehensive assessment should include evaluation of the patient's: • Plan of Care • Medications • Pre/intra/post and interdialytic blood pressures, • Interdialytic weight gains • Target Weight vs. Ideal Dry Weight • Related intradialytic symptoms (e.g., hypertension, hypotension, muscular cramping) • Along with an analysis for potential root causes. Root Causes of Intradialytic Morbidities – Posture – Low O2 saturation – Medications / Antihypertensives – Incorrect Ultrafiltration rate – Hypotonic environment / Hypoalbuminemia – Dialysate at body temperature or warmer: core body heating – Splanchnic vasodilatation secondary to food ingestion – Electrolyte/Acid-Base Imbalance – Incorrect dialysis bath for individual patient – Severe anemia (HCT <30) / Occult hemorrhage – Unstable cardiovascular status / Arrhythmias / Pericardial tamponade / MI – High Output failure related to high access blood flow rate (QA) – Septicemia – Dialyzer reaction, Hemolysis and Air embolisim Root Cause Analysis Thru The Crit Line Monitor • Anemia • Hypoxemia • Oxygen carrying capacity • Hypervolemia • Hypovolemia • UFR is incorrect: too fast / too slow • Patient is at dry weight • Position effects • Effects/ need for hypertonic; replacement fluid • Low cardiac output ( SvO2 ) • Effects of eating Administration's Next Step • Assign a Fluid Manager to each facility • Provide necessary technology • Incorporate competency based fluid management & CLM training in orientation and annual in-services • Educate patient / families on fluid management • Ensure use of monitors each shift • Approve Hema Metrics " Recommended Guidelines" for CLM use • Order / reinforce "Dry Weight / Refill Checks" PAGE 1 Administration's Next Step • Round / Review profiles and tracking tools with staff • Assess Medications on ongoing basis • Reassess protocols for Sodium Modeling, Eating, use of Oxygen and Thermal Control • Review hospitalization diagnosis for accuracy • Analyze Root causes of IDM with staff • Add Fluid Management into the facility QAPI program PAGE 2 Potential Quality Indicators • Hospitalization rate : Hospitalization Causes • Intradialytic events: Number / Type / Cause • Incidence of Hypoxemia • Access Morbidity • Anemia Management : Hemoglobin variability • Albumin levels • Dry Weight changes PAGE 1 Potential Quality Indicators • Reduction in BP meds • Left ventricular mass index (echo) • Morbidity/ Mortality • Economics • Quality Of Life • Patient Satisfaction • Skipped Treatments / Early sign offs PAGE 2 End – Section 2 Thank you for taking time to learn about the new CMS Conditions of Coverage as they relate to fluid management, and how the Crit-Line will assist you in achieving the new mandates. Additional Information • Please call 1-800-546-5463 if you would like additional information or would be interested in evaluating Crit-Line at your clinic • Additional information can also be found at www.hemametrics.com
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