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Jennifer Chen, PharmD, CGP
PharmaTech is recalling all liquid products due to a potential risk of product contamination with B. cepacia. This recall is to the retail/consumer level. The affected product started shipping October 20, 2015 and the affected companies include Rugby, Major, Bayshore, Metron, Centurion and Virtus. Besides Diocto liquid as previously posted, Senna syrup, Senexon liquid and various liquid vitamins are also affected in this recall. More information regarding recalled drug products, NDC number and lot number can be found on the FDA website. It is advised to check your patients who are currently using these products and evaluate if they are affected by this recall. Our client may request a claim report to be generated to help identify which patients are impacted by this recall at your hospice.
Jennifer Chen, PharmD, CGP
PharmaTech, the manufacturer of the Rugby-branded product is recalling all non-expired lots of the stool softener, Diocto (docusate sodium) Liquid due to a risk of product contamination with B. cepacia. As mentioned in previous blog article, the use of oral docusate liquid contaminated with B. cepacia may result in serious infections that could be life-threatening in patients with compromised immune systems and in patients with chronic lung conditions.
Diocto Liquid comes in one pint (473mL) bottles and was distributed nationwide to wholesale and retail facilities including hospitals and pharmcies. All lots with the NDC 0536-0590-85 (50mg/5ml) are included in the recall. The FDA and CDC continues to recommend that clinicians and patients not use liquid docusate sodium product from any manufacturer for any medical purpose.
Jennifer Chen, PharmD, CGP
Last month, the CDC and FDA investigated a multi-state outbreak of infections caused by Burkholderia cepacia complex. B. cepacia complex is normally not a pathogen in the ambulatory setting, but may colonize and/or infect the respiratory tract of patients with cystic fibrosis or bronchiectasis. Symptoms can vary widely, ranging from mild respiratory symptoms to serious respiratory infections, especially in patients with compromised immune system. The reported infections were primarily in ventilated patients without cystic fibrosis and who were being treated in intensive care units. Preliminary information indicated that contaminated liquid docusate products may be related to these cases. At the time, the CDC recommended that facilities not use any oral liquid docusate products for patients who are critically ill, ventilated or immunosuppressed.
The CDC is continuing to work with the FDA to investigate this issue. Forty-seven B. cepacia complex cases have now been confirmed in five states. The CDC also confirmed that two samples of unused oral liquid docusate product received from one of the affected hospitals have tested positive for B. cepacia complex. The FDA is currently testing multiple liquid docusate products that are linked to the cases.
The CDC has now expanded the warning to all patient populations, including hospice patients, and recommends that clinicians not use any liquid docusate product, as a stool softener or for any other medical purpose. Patients who are currently using oral liquid docusate as laxative should be transitioned to an alternative product such as senna-docusate tablet (may be crushed), liquid senna, sorbital or Milk of Magnesia.
B. cepacia bacteria are often resistant to common antibiotics and decisions on the treatment of infections should be made on a case-by-case basis. Healthcare providers should remain on alert for infections caused by B. cepacia complex and inform infection prevention staff immediately when these infections are identified. Cases should be reported to state or local public health authorities. More information and further updates regarding this outbreak can be found on the CDC website.
Jennifer Chen, PharmD, CGP
Nuplazid (pimavanserin) has recently received FDA approval for the treatment of hallucination and delusion associated with Parkinson's disease. It is an antipsychotic medication targeting only on the serotonin pathway. The FDA approval was based on a 6-week, randomized, placebo-controlled study (1). In this study, 199 patients were randomized in a 1:1 ratio to Nuplazid 34mg or placebo once daily. The treatment group resulted in a 37% improvement compared to a 14% improvement for those taking placebo. There are currently no head to head studies comparing Nuplazid with existing antipsychotic medications.
Typical Parkinson's disease therapy consists of drugs that stimulate dopamine to treat the patient's motor symptoms such as tremor and muscle rigidity. Existing antipsychotics target both the dopamine and serotonin pathways in the brain and so they can interact with the pathways that help regulate the movement disorders in Parkinson's patients. Nuplazid, as a selective serotonin inverse agonists (SSIA), preferentially binds to 5-HT2A receptors and has no activity at dopamine receptors so it is not likely to aggravate Parkinson's disease.
Nuplazid is supplied as tablets for oral administration and is now available in the United States. The recommended dose is 34 mg per day, taken orally as two 17-mg tablets once daily, without titration. There is no dosage adjustment needed for patients with mild to moderate renal impairment. However, the use is not recommended for patients with severe renal and hepatic impairments as it has not been evaluated in these patient populations. The dose should be reduced to 17 mg per day when taken with a potent CYP3A4 inhibitor such as statins or ketoconazolethe.
The most common adverse effects noted in the clinical trial were peripheral edema and confusion. Similar to existing antipsychotic medications, Nuplazid comes with the black box warning regarding the increased mortality in elderly patients with dementia-related psychosis. It also prolongs the QT interval so the risk of the occurrence of torsade de pointes is increased in patients with known QT prolongation or in combination with other drugs known to prolong QT interval. Therefore, Nuplazid should be avoided in patients with known QT prolongation or in combination with other drugs known to prolong QT interval and should also be avoided in patients with a history of cardiac arrhythmias and the presence of congenital prolongation of the QT interval.
Place in Hospice Therapy
Although Nuplazid has a novel molecular approach to treat Parkinson's psychosis, its use may be limited in the hospice setting. It has a very long half-life of 57 hours and takes 12 days to reach steady state. According to the phase 3 trial, the significant difference in the efficacy between Nuplazid and placebo was not seen until week 4. In addition, Nuplazid can be cost-prohibitive ($2340 per month) compared to existing antipsychotics, which are available as generics. Atypical antipsychotic such as Seroquel, has less anti-dopaminergic properties and demonstrated efficacy on Parkinson's psychosis in clinical studies, so it is more cost effective than Nuplazid in the management of Parkinson's psychosis.
Nuplazid® [package insert]. San Diego, CA: Arcadia Pharmaceuticals, Inc; 2016.
|That is disturbing that FDA would approve this drug after such a small, short trial, with limited benefit relative to placebo.
-- Linda
Posted 7/13/2016 08:29:23 AM
Jenny Chau, RDH, PharmD
Brintellix (vortioxetine) is a relatively new serotonergic antidepressant, approved to treat major depressive disorder in September 2013, as described in our previous blog. In recent FDA MedWatch news, there were numerous reports of name confusion between Brintellix and the antiplatelet drug, Brillinta, not only among the consumers, but also among healthcare professionals. On May 2, 2016, the FDA approved a brand name change from Brintellix to Trintellix in order to decrease the risk of prescribing and dispensing errors. As of June 2016, Brintellix will be marketed as Trintellix and will also have a new National Drug Code (NDC).
Although there is a new brand name and NDC, the formulation, indication and dosages of 5 mg, 10 mg and 20 mg tablets will remain the same. Pharmacies, insurance carriers and healthcare providers are advised to update their medication-related electronic systems with the new brand name. During the transition to the new brand name, healthcare providers are also advised to carefully check to make sure they have prescribed or dispensed the correct medication and educate patients about the name change.
The FDA also encourages patients and healthcare professionals to report medication errors, name confusion, adverse events or side effects related to the use of vortioxetine (Brintellix/Trintellix) and Brillinta by calling FDA's MedWatch Program at 800-332-1088 or visit http://www.fda.gov/Saftety/MedWatch.
FDA Drug Safety Communication: FDA approves brand name change for antidepressant drug Brintellix (vortioxetine) to avoid confusion with antiplatelet drug Brillinta (ticagrelor). (2016, May 2). Retrieved from http://www.fda.gov/Drugs/DrugSafety/ucm497942.htm.
Jennifer Chen, PharmD, CGP
The FDA has withdrawn approvals for the use of niacin or fenofibrate in combination with statins for the treatment of high cholesterol. The FDA also withdrew approval of the indications related to the adjunctive therapy to a statin with niacin extended-release tablets (Niaspan) or fenofibrate delayed-release capsules (Trilipix). This decision directly impacts two medications, Advicor and Simcor, both contain niacin with a statin (lovastatin and simvastatin, respectively) and they are no longer on the market.
The FDA made this decision based on several large trials including AIM-HIGH, ACCORD and HPS2-THRIVE, which collectively showed no benefits of adjunctive therapy to statins for the reduction in the risk of cardiovascular events. According to the studies, further reduction of LDL cholesterol did not translate to the reduction of cardiovascular events. In the absence of benefits, serious adverse events such as myopathy were statistically significantly higher in patients taking niacin with statin.
Niacin and fenofibrate are still available individually on the market. While niacin is also available over-the-counter, patients medications should be reviewed and patients should be educated on efficacy concerns about combination therapy as the benefits of the drugs no longer outweigh the risks.
Preventive care, referring to medical interventions with anticipated long-term benefits, is often inappropriately continued near the end of life. Majority of patients, who were on cholesterol-lowering medications prior to starting hospice, remained on the therapy. This is a great opportunity for hospice care providers and patients to discuss the appropriateness of continuing preventive care as part of an important conversation about prognosis. As patients are often worried about the risks associated with discontinuation, recent studies have shown that the discontinuation of statin therapy in the setting of advanced illness is actually safe and may be associated with benefits. These benefits include improved quality of life, reduced pill burden and reduction in medication costs.
Our pharmacists have put together a patient directed letter to help you communicate with your patients regarding the discontinuation of cholesterol-lowering drugs. This letter can be found in the clinical resources section of member section.
Jenny Chau, RDH, PharmD
Hospice Pharmacy Solutions (HPS) and Outcome Resources (OR) have dedicated clinical pharmacists, who work with our hospice providers, to provide quality care to the hospice patients we serve. Many of the clinicians at the hospices we work with may not be aware that our clinical pharmacists provide a wide range of clinical support services and are available 24/7. This article will focus on some of the core, highly rated services that are valued by hospice providers. These clinical support services include: pharmacist medication reviews, pharmacists consultations, newsletters and blog articles, educational presentations and online clinical resources.
Pharmacist Medication Reviews
Comprehensive medication reviews provided by our clinical pharmacists exceed the standards of the Medicare Conditions of Participation (CoP). The medication review service helps many hospice providers to stay in compliance from patient being admitted to discharge. Medications were reviewed not only at admission, but also re-reviewed in accordance to each hospice interdisciplinary team (IDT) meetings depending on the hospices' need. In each medication review, our clinical pharmacists make recommendations on coverage decisions, highlight any cost-effective therapeutic alternatives, identify clinically significant drug interactions, and point out any therapeutic duplications to help decrease cost and adverse effects. At the end of each medication review, a personalized summary of recommended action items is provided to help with disease and symptoms management. Our medication reviews are unique and highly rated for providing clear and concise recommendations for the Interdisciplinary Team (IDT) to help improve quality of patient care, reduce medication cost and stay compliance with CoP.
Pharmacist Consultations
Pharmacist consultations are available 24/7 every day in the year. This is a great opportunity for nurses, physicians and pharmacists to collaborate and provide the best possible care to your patients. Our clinical pharmacists are here to help discuss any medication and/or symptom related topics relating to your patients. Common topics include: opioid dose conversion, pain and palliative symptom management, and general drug information (i.e. availability/formulation, therapeutic alternatives, cost and adverse effects).
Newsletters and Clinical Blogs
Our newsletter, The Clinician, and our clinical blog contain original hospice oriented articles that are prepared and chosen carefully by our clinical team. The Clinician is our quarterly newsletter that focuses on hospice pharmacy, drugs and guidelines updates. Some of the hot topics in our newsletters include Opioid Infusions in Hospice Patients, COPD and Inhaled Corticosteroids, and Diabetes Management Decisions in Hospice. There are over 10 years of past issues of The Clinician archived on our web-site for easy access. Our clinical blog articles are posted more frequently on our website to address timely clinical issues to help you stay current on drug information and other hospice related topics.
Educational Presentations
We provide three different types of educational presentations: a monthly webinar series called Pathways to Success, customized live in-service presentations tailored to the clients' needs, and pre-recorded self-paced educational presentations. We are accredited by the California Board of Registered Nurses to offer nursing continued education (CE) credits and all of these presentations are available for nursing CE. Pathways To Success Live Webinar Series is our monthly continuing educational series provided via web-based interactive presentations. The webinars feature guest speakers or HPS/OR clinical pharmacists on various hospice related topics such as Referral Inquiry to Admission: Growing Your Census, Management of Delirium in the Hospice Patient, and many more. In addition, our clinical pharmacists also design and provide clinical education on topics that our hospice partners are interested in and provide live in-service presentations. Some of the very population educational presentations were recorded and made available as self-pace webinar courses, which our hospice partners can register online and complete at your own convenience.
Clinical Resources
Our exclusive member login website contains an extensive selection of various clinical resources, charts, protocols, clinical algorithm and pathways, and other tools to assist hospice clinicians in many areas of practice. These are printable documents that hospice providers can keep in their pockets for convenient access. A few examples of our clinical algorithms include: Nausea and Vomiting Management, Anxiety and Agitation Management, and Hallucination Management. Another very popular clinical chart is our Inhaled Respiratory Medications Chart, which help clinicians easily identify and avoid therapeutic duplication in respiratory medications.
In addition, we understand that drug discontinuation at end of life may be difficult for patients and families to understand. We have developed handouts on specific drugs recommended for discontinuation in hospice patients. These are written specifically towards patients and family members and nurses have found them helpful as a communication tool. Examples of the handouts include: Discontinuation of Anticoagulants, Cholesterol Lowering Drugs, and Cognitive Enhancement Drugs in end stage dementia.
Hospice Pharmacy Solutions and Outcome Resources provide you with pharmacy clinical support 24/7, 365 days a year with one goal in mind, which is to help you succeed as a hospice provider. Talk to one of our HPS or Outcome Resources representatives to learn more about our clinical services. For more information on our exclusive member login, please visit https://members.outcomeresources.com/memberlogin.asp or contact your Account Manager. We look forward to our future collaboration!
Jim Joyner, PharmD, CGP
The US Food and Drug Administration has issued new labelling requirements for all fluoroquinolone antibiotics due to serious risks for disabling and potentially permanent adverse effects. The new labelling will state that these antibiotics should not be used in patients with uncomplicated infections because the risks generally will outweigh the benefits. FDA mentions these specific infections as examples where Fluoroquinolone risks outweigh the benefits: sinusitis, bronchitis, and uncomplicated urinary tract infections.
The serious risks cited by the FDA include: tendon rupture, peripheral neuropathy, QT prolongation with torsades de pointes, phototoxicity, central nervous system effects, and exacerbation of myasthenia gravis.
Fluoroquinolones have been known to have the potential for serious adverse effects for a long time prior to this latest move by the FDA. In 2008, the FDA required these antibiotics to contain a black-box warning because they increase the risk of tendonitis and tendon rupture by three to four-fold. Other serious reactions reported are: retinal detachment, hallucinations, psychotic reactions, acute kidney failure, depression, painful rashes, and hearing problems.
A 2001 study by Dr. Jay Cohen (1) documented the following fluoroquinolone adverse reaction rates:
a) Nervous system symptoms occurred in 91% of patients (pain, numbness, dizziness, weakness, anxiety, psychosis, and memory loss).
b) Musculoskeletal symptoms in 73% of patients (tendon ruptures, tendonitis, joint swelling)
c) Sensory symptoms in 42% of patients (tinnitus, altered vision, olfactory and auditory disturbance)
d) Cardiovascular symptoms in 36% of patients (tachycardia, shortness of breath, chest pain, palpitations)
Due to the serious risks for major debilitating adverse effects, fluoroquinolone antibiotics should only be deployed in serious infections where other options are not available. It is uncommon that a fluoroquinolone would be the only antibiotic that could be used.
1. Cohen JS. Peripheral Neuropathy with Fluoroquinolone Antibiotics. Annals of Pharmacotherapy 2001, Dec;35(12):1540 47.
Jennifer Chen, PharmD, CGP
Fixed-dose combination therapy offers convenient dosing and improves compliance; however, their place in hospice therapy is limited and these novel inhalers are expensive. This article will discuss new fixed-dose combination therapies, their limitation and the cost-effective alternative for hospice patients.
LAMA/LABA combination
Inhaled bronchodilators are the cornerstone of treatment in COPD. Both long-acting muscarinic antagonists (LAMAs) and long- acting beta 2-adrenergic agonists (LABAs) are used as long-term maintenance treatment of airflow obstruction in patients with COPD. The fixed-dose combination inhalers are designed to provide extra bronchodilation compared with either therapy alone. Currently, Anoro Ellipta (umeclidinium-vilanterol) and Stiolto Respimat (tiotropium-olodaterol) are the only FDA approved LAMA/LABA combinations available on the market that may be given in a convenient once daily dosing.
Two new LAMA/LABA combination inhalers received FDA approvals but not yet available on the market. Utibron Neohaler (glycopyrrolate-indacaterol) and Bevespi Aerosphere (glycopyrrolate-formoterol), approved in Oct 2015 and April 2016, respectively, offer another option of LAMA/LABA dual combination bronchodilator to patients with COPD. Both inhalers contain the same long-acting muscarinic antagonist, glycopyrrolate, with the different LABAs (indicaterol versus formoterol). Both of these new inhalers are given twice daily.
One of the notable differences between all of these products is the type of inhalation device used. Anoro Ellipta and Utibron Neohaler deliver medication via a dry powder inhaler whereas Stiolto Respimat and Bevespi Aerosphere use a metered-dose inhaler. Both of these devices are breath-actuated, that is, requiring effective positive respiratory effort to inhale medication.
ICS/LABA combination
Inhaled corticosteroid (ICS) therapy is recommended as combination treatment with LABA for patients with a history of frequent acute exacerbations of their COPD. Breo Ellipta, approved in April 2015, combines the new LABA vilanterol with an inhaled corticosteroid already on the market, fluticasone. Vilanterol allows this product to be dosed once daily compared with existing ICS/LABA combination products that are dosed twice daily including Advair Diskus (fluticasone-salmeterol), Symbicort (budesonide-formoterol) and Dulera (mometasone-formoterol).
Long-term ICS treatment is associated with multiple adverse effects including fractures, oral fungal overgrowth and respiratory infections. Therefore, treatment with ICS in patients with COPD should be carefully evaluated when assessing the risk/benefit ratio due to the risk of pneumonia. Their benefit in patients at low risk of exacerbations is questionable1.
Place in hospice therapy
The major disadvantage of these combination therapies for the hospice patient is the method in which the medication is delivered via a metered-dose inhaler or a dry powder inhaler. In patients with advanced disease, who may not have enough positive inhalation, nebulized therapies may be more efficacious than inhalers. Therefore, the combination treatment of short-acting muscarinic antagonist (SAMAs) and short-acting beta 2- adrenergic agonist (SABAs), such as DuoNeb (ipratropium-albuterol) is usually recommended as an alternative. Routine use of DuoNeb should provide an equivalent coverage compared to LAMA/LABA combination products. Although the dosing frequency (four times daily) may be considered as a drawback compared to the long-acting combination products, the short-acting combination therapy may also be used on as-needed basis for acute management of dyspnea in addition to the scheduled dosing. Since the newer combination products are generally cost prohibitive, DuoNeb also serves a cost-effective alternative for hospice patients. In cases where a patient has high risk of exacerbation, a low dose oral corticosteroid may be considered and they are inexpensive compared to inhaled corticosteroids.
View a comparison chart of fixed-dose combination inhalers and cost-effective alternative.
A complete chart on inhaled respiratory medications with dosing information and pricing can be found in the Clinical Resources in our member section.
Jim Joyner, Pharm.D., C.G.P.
CMS has established very restrictive regulatory criteria for the use of Haloperidol and other psychotropic drugs for patients who reside in the SNFs. These criteria include restrictions on indications for use, duration of therapy, daily dose limits, monitoring, and more. The information is spelled out in F-329 Unnecessary Drugs (CMS Skilled Nursing Facility Regulations). The regulations are intended for nursing home patients who are NOT being treated under "end of life care" and this is clearly spelled out in F-329.
F-329 Unnecessary Drugs contains specific language that provides an exception to the specific criteria for antipsychotic drug use (including Haloperidol) for hospice patients in the SNF. Subsection 483.25 (l) in this F-tag contains an extensive table (Table 1) which lists examples of numerous medications for which CMS is concerned about, including all antipsychotic drugs. At the end of this extensive table is a section titled, simply, "Exception". Here is the exact language:
This means that when Haloperidol (or any antipsychotic drug) is being used for managing symptoms at end-of-life in the SNF, the regulatory criteria on max dosage, duration of therapy or related issues do not apply. Haloperidol is used extensively in hospice and palliative care for management of terminal delirium, severe agitation of end-stage dementia, and for management of nausea – vomiting. It is highly effective for these indications and generally well tolerated in many hospice patients, however in many cases, doses greater than 2 mg per day are required and are clinically appropriate. Haloperidol is recommended as a drug of choice for terminal delirium by several well respected palliative care experts and organizations (references available upon request if you need them).
Make sure that the patient's health record clearly indicates that the patient is under hospice for 'end of life' care.
|Thank you! We've been getting pushback from NH Facilities recently on what would normally be considered mild dosages for a hospice patient. I've passed out copies of this to all our Nurses.
-- Allen
Posted 5/20/2016 07:13:16 AM
|How does this relate to the more recent CMS initiative to decrease anti-psychotic use in LTCFs by 15%? We have facilities whose star ratings are being affected by the use of Haldol for N/V. Additionally, a patient cannot utilize the hospice benefit and the SNF benefit simultaneously so wouldn't that immediately eliminate our patient population?
-- Jess Smith
Posted 5/2/2016 12:56:58 PM
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Education Resources and Support for Hospices
Stay up-to-date on the latest hospice pharmacy benefits management information and tools with a variety of education resources and support at no extra charge. We offer presentations live at your facility, over the Internet or viateleconference, online service education programs, customized courses, and courses accredited for nursing continuing education credit.
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Homer High School's SkillsUSA membership would like to thank the Homer Rotary Club for the support and speaking opportunity given to us recently. As our community and nation reassess the importance of the career technical trades and the role public school plays in preparing students, we are thankf...Wed, 05/08/2013 - 4:39pm
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"We're going to need a lot of help, the more the merrier," George West Chamber of Commerce Director Rena McWilliams said.
Part of the celebration so far will involve remembering the veterans of the Vietnam War by bringing a traveling Vietnam Wall memorial to George West on Sept. 17, 2014. There are multiple traveling wall replicas of the real memorial in Washington, D.C., and the one that's in the works for George West is supposedly the largest one at 80 percent.
"What can you do to get people to come and celebrate if not to celebrate the veterans," Mayor Steele asked. "It's just one of those things – that everyone has someone in their lives who is a vet. To me, it's important because my husband is a vet. It's a wonderful thing to celebrate."
The Grace Armantrout Museum is behind bringing the wall to George West, but the contract isn't set in stone yet. The museum is currently seeking donations to help cover the estimated cost of $8,000.
Although the memorial is tentatively set to be the centerpiece of the festivities, the city and chamber are seeking volunteers to join the centennial committee and brainstorm ideas for how the town should ring in its centennial year and to help make it happen.
"We're going to have our organization meeting in the not-too-distant future," McWilliams said. "We don't have plans firm, but the city and the chamber are going to be working together."
George West City Manager Sandra Martinez told the city council that several people have come to city hall and the chamber of commerce already to discuss preparations for the centennial during their meeting on June 19. The city council unanimously approved helping fund the centennial events for 2014.
"The excess of money in the HOT funds could be used for the centennial, which could be used for heads-to-beds," Martinez said. "Everyone should be involved because this is celebrating the city's birthday."
Hotel occupancy tax funds are set aside exclusively for events that promote tourism. These tax funds are how Three Rivers is funding its centennial celebration next week.
As a centennial celebration, the town's history will be a common theme through the year. The George West Chamber of Commerce is seeking information on families who played a role in the founding of the town and its early years for a series of feature articles on founding families to be printed in The Progress throughout 2014.
McWilliams suggested the Canfield family, owners of the early local grocery store, as one of the families to feature in the historical articles. But she is open to suggestions for more families.
"I think it will come together, be a big project and be successful and the natives of George West will have something to be proud of," she said.
McWilliams encouraged anyone with information and early photos to contact the chamber.
To get involved with the brainstorming and planning process for the George West centennial, contact the George West Chamber of Commerce at 449-2033 or McWilliams at 362-3322.
"It's just overwhelming when you see it's coming, and time is running tight on this already," Steele said.


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"I am a cradle Catholic and my husband of eight years just went through RCIA this Easter. Praise the Lord! His conversion was due, in large part, to your show and the awesome answers of Tim Staples, Jimmy Akin, and the rest of the gang. Your show has helped me, my now husband, grow deeply in love with the Church."
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"Between heresy and schism there is this difference, that heresy perverts dogma, while schism, by rebellion against the bishop, separates from the Church. Nevertheless there is no schism which does not trump up a heresy to justify its departure from the Church."
~ St. Jerome, (In Ep. ad Tit., iii, 10), remarking on how practically and historically, heresy and schism nearly always go hand in hand.


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The Farmking of Nigeria: 4-in-1 Farming device
Sulaiman Famro is a cheerful, 65 year old engineer, and a master of branding. He built the prototype "Farmking" three years ago and claims he can save the country $1 billion a year, just in savings on starch importation. The … Read more →


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Game 2 – Live Blog
Top of the 4th
6:25 PM (PST) – OK, finally home. It took me 45 mins to go 4 miles because it's raining in LA. Angelenos can't drive in the rain. Let the live blogging begin.
I love how Eckstein runs hard to 1st base when he gets walked. He's so Scrappy, he's like Scrappy Doo. Except he's not annoying like Scrappy Doo.
Woohoo – Eckstein steals and takes 3rd on LoDuca's errant throw!
Dang – Duncan strikes out. I hope he's not falling victim to the pressure of being in the NLCS.
Thoughts on the game so far: I've been watching via Gameday and then listening on the radio on the way home. I got deja vu with Carp having a rocky 1st inning and then the Cards battling back in the top of the 2nd. I still kind of thought we could have gotten another run or two once we had the bases loaded with nobody out, but I'll take the 2 we got. I love that Jimmy homered – we so need him to be hot right now.
Bottom of the 4th
Mary (Haiku of the Week winner) – Could Tony pile any more Cardinal clothing on? Perhaps some accessories – a Cardinals tongue stud or nose ring?
Stylish glove flip by Belliard – not fast enough to get the double play with Reyes running. Two down.
Carp looks like he's settling down a bit. Phew.
Top of the 5th
Bradford has such a strange delivery – practically dragging his knuckles on the ground.
Nice hit by Jim, but he didn't quite get enough of it.
A 1-2-3 inning from the middle of our order – that's, shall I say, sub-obtimal.
Bottom of the 5th
Beltran grounds out to Albert. Like Toni Braxton, I can breathe again.
Home run Delgado. Sigh.
Single by Green. I hate to say it, but I think we gotta get Carp out of there. He's Atlas, but he's shrugging. You can only carry the weight of a team for so long.
Valentin flies out. 2 down.
OK, nice finish to the inning by Carp. Chavez grounds out and we're only down by 1.
Top of the 6th
2 down, but a base hit by Molina. J-Rod to pinch hit, so the Mets are making a pitching change. I hope J-Rod does something creates some fodder for his blog.
OK, nothing to blog about there – that at-bat was briefer than one of my haiku blog entries.
Bottom of the 6th
Hancock coms into the game. A walk to Reyes. I'd like to see him attempt to steal and challenge Molina.
Double for Lo Duca and Reyes scores. FOX informs us that 16 innings of scoreless pitching for our bullpen comes to an end.
Flores comes in. Great play by Belliard! Makes up for previous error, which I wouldnt have dubbed an error. For a big guy, he's really agile.
Top of the 7th
Nobody on base for Pujols again. It's disheartening.
These commentators are being awfully hard on Albert. Dude is just waiting for his pitch. I hope his single shuts them up. Come on, Jimmy!
Edmonds gets walked. Come on, Speizio!
Yes! Spiezio comes through with a 2-run triple. It appears the umps made the ri
ght call, and that it wasn't a home run. Tie game. La Genius made the right call in benching Rolen today.
Bottom of the 7th
No matter how this one ends (well, OK, it does matter), I like the way we're battling back tonight. Quid Pro Quo all the way.
Jim Edmonds compared to Kelly Leek of The Bad News Bears? I don't think so…but there was an interesting story about Jackie Earle Haley, the actor who played Kelly in the LA Times recently.
Top of the 8th
Heilman pitching. Single by Molina – his 3rd hit tonight!
Gutsy at-bat from Eckstein but he can't quite finish it.
Bottom of the 8th
Delivery guy's here – Dinner break
Top of the 9th
Taguchi homers! I'll have to admit I was questioning TLR when he replaced Duncan with Taguchi in the last inning. I just am not sure that Taguchi is that solid of a defensive outfielder anymore, and I thought we'd have a better shot with Duncan batting in the 9th. So that's what TLR is the manager and I'm the blogger. 😉
Pujols doubles, with some smart base running. Spiezio comes through again! 9 – 6 Cards!!
Bottom of the 9th
Johnson strikes out Delgado – nicely done. One away.
Great play by Rolen – diving catch and he gets him. Two away.
Ground out – That's a winner! It's a huge win for the Cards – now we get to play 3 in STL. Time for me to relax with a frosty Busch – oh wait, they don't sell Busch in LA. Bud will have to do.
14 Comments
Were you watching the new Game Day or the traditional version. You can flip back and forth by clicking Gameday in the upper right. I guess I'm a traditionalist for the time being. Like the box score.
ok i love the cardinals but my shawn green is playing against them.but i have to root for the cardinals.
Phil, I was watching the new one. I like the improved pitch placement and the info on the hitter's past at-bats. Gameday in general stresses me out. It's just too long of a wait when you see that "ball in play" message.
Kaylee, I know how you feel – it's like the 1-70 world series when my crush on George Brett interfered with my love for the Cards – but ya gotta root for the Cards!
yeah i know I have to go against my beloved shawn green for this series
Does Duncan scare any of the rest of you???? I know he's a first baseman, but jeez, didn't Dad tell him to use 2 hands?
Need another comeback.
hey isnt that delgado"s seecond homer?
agreed – he's gotten better out there but he does scare me. I didn't really think Belliard deserved that error – maybe for his throw but it was a tough stop.
Hancock wears #32. Can you name the most most famous Redbird pitcher to wear that number?
WOW! That makes up for the 'error' and saves a run.
#32…i was thinking Bob Forsch, but I looked him up and he was #31. Who was it?
I've been packing and watching. My brother Bruce and I were in StL when Spiezio tripled with the bases loaded. I like that guy – imperial and all.
Ok, there were 2 "acceptable" answers. The first Hall of Famer, Steve Carlton, although he had his best years with the Phils, YAY YADI!!!! Infamous might describe the second better – Ernie Broglio who was the main name in the trade that brought Lou Brock to the Cards!! Cubs fans still cry about that trade.
I hope you didn't have to leave the TV to eat!!
Taguchi traded
His stocking hat for a bat.
BIG Home Run to left!
Ok HOLD'em in the ninth!
Spiezio and So
Justify LaRussa's moves
Come-from-behind WIN!
Julie – Great Job – thanks! It was fun watching the game this way. Brother Bruce and I are leaving tomorrow morning, playing golf if it's nice and going to the game tomorrow night. (I wish I had a camera phone – I could send a picture from the park!) Sunday I fly to Florida for a week. It sure would be nice to win all 3 in St. Louis. We'll see.
Hey, I missed the first four innings tonight because I had to go see my alma-mater high school football team play, and it was also homecoming night. But I enjoyed the 45 minute trip home listening to the game on my XM radio. Come to think of it I didn't enjoy that part of the game. It wasn't until I got home in the top of the 7th that the action started. I think it was reassuring for me that we could win this game without solely depending on Carp. I loved how our guys stepped up to come from behind and win. tomorrow will be a brand new day, the series is tied 1-1, and we'll be home. I really enjoyed reading your inning by inning descriptions and insights. GO REDBIRDS!!!!!


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Marker: Empire Trracer
Condition: 7/10
Color: Black
Upgrades: None
Known Problems: None
Asking Price: $65 shipped
Shipping Options: USPS unless otherwise specified. Buyer would pay difference of alternative.
Trades of interest: None
Location of item: San Antonio, TX
What is Included: Marker, Velocity Adjustment Tool, Parts Kit that comes with gun, Barrel Sleeve
Gun works well and I haven't had a problem with it. Only problem is a scratch on the area where tanks screw in. When trying to remove an ASA reducer I accidentally scratched it. Comes with aftermarket 1911 grips. Makes no difference really. This would be a great beginning pump gun, or a loaner/backup/stockclass marker (with a few additions).
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Graduate Program Admission Requirements
Admission to the TWU Graduate School. Transcripts and TOEFL scores should be submitted to: Admissions Processing, P.O. Box 425649, Denton, TX 76204.
Admission to Women's Studies. In addition to the Graduate School's admissions criteria, applicants must meet admission criteria of the Department of Women's Studies.
The Department of Women's Studies Admission Requirements
- An approved application to the TWU Graduate School
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- A 3 to 5 page written statement about your career goals and professional development as they relate to Women's Studies
- Two letters of recommendation (preferably from professors, if possible)
- An 8-10 page writing sample, preferably a paper from an academic course (we encourage but do not require you to use a scholarly format with works cited).
The letters of recommendation, written statement, and a writing sample should be sent to the Department of Women's Studies, Texas Woman's University, P.O. Box 425557, Denton, TX 76204-5557, or may be emailed as attachments to email@example.com.
We encourage applicants to reveiw the NWSA GUIDE TO GRADUATE WORK IN WOMEN'S/GENDER STUDIES before submitting their applications.
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For fall admission February 1 is the preferred deadline for the receipt of application materials. For spring admission October 15 is the preferred deadline for the receipt of application materials. Materials will be accepted after the preferred deadlines on a case-by-case basis.
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Birth to 5: Watch Me Thrive! promotes early developmental and behavioral screening for kids
The U.S. Departments of Education and of Health and Human Services have launched Birth to 5: Watch Me Thrive! to encourage developmental and behavioral screening for children to support the families and providers who care for them. Birth to 5: Watch Me Thrive! will help families look for and celebrate milestones; promote universal screenings; identify delays as early as possible; and improve the support available to help children succeed in school and thrive alongside their peers.
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2010 U.S. Department of Education Reading Institute and Early Learning and Development: Birth to Third Grade Strand
The U.S. Department of Education convened the 2010 Reading Institute, in Anaheim, California, July 19-21, 2010. This year, for the first time, the Department of Education collaborated with the U.S. Department of Health and Human Services and the National Institute for Literacy to offer a separate Early Learning and Development Strand at the Institute. The Early Learning Strand offered sessions on developmentally appropriate practices in language and literacy for children from birth to third grade, and on planning and building comprehensive early learning systems and infrastructure. The presentation slides from these sessions, along with audio podcasts of seven featured sessions, links to pre-Institute webinars, and other resources, are available at the post-conference website: http://www.mikogroup.com/2010readinginstitute.
2010 Indian Demonstration Application Available
The Notice inviting applications for the 2010 Indian Demonstration Grant program was published on December 3, 2009. The purpose of the Demonstration Grants for Indian Children program is to provide financial assistance to projects that develop, test, and demonstrate the effectiveness of services and programs to improve the educational opportunities and achievement of preschool, elementary, and secondary Indian students. The official open and closing dates are as follows:
- Grant Application Opens: December 3, 2009
Grant Application Closing Date: February 18, 2010
More information, including the official Federal Register Notice may be found at the following link: www.ed.gov/programs/indiandemo/applicant.html
(December 7, 2009)
2010 Formula Grant EASIE Registration is Open
From November 13 to December 11, 2009 current Indian formula grantees will be able to register for the 2010 formula grant application. Registration is needed to have access to Part I of the EASIE online application. The following dates have been established for the 2010 Indian Formula Grant aplication cycle:
- -Registration opens on November 13, 2009
-Registration closes on December 11, 2009
-Part IA will open on January 4th, 2010
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While this green tea would be a very good tea for beginners, even seasoned green tea fans appreciate this sencha. One of the few second harvest green teas we sell, we carry Daily Sencha because it is an above average quality sencha and offers a very good quality-to-price ratio. This green tea is far and away better than what you will find at most grocery or health food stores and is freshly packaged in Japan within a very short time of when you purchase it. This item is a blend of green tea leaf from Japan's Southern Kyushu tea growing region. Be sure not to brew with too much heat or for too long or it can be overly bold.
Fresh from Japan, it comes in 100gm (3.52 oz) packaging.
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Pierre used to be a very timid and reserved child, and he rarely talked with his neighbors. He liked to be alone.
It can be difficult to understand what a child is going through, so helping Pierre sometimes felt impossible. But after three years of attending the child development center, Pierre is no longer the shy boy he once was.
When Pierre's sponsor came to visit the boy for a second time, he immediately noticed a difference in his sponsored child.
On this visit, Pierre waved his hands with a joyful smile to welcome his sponsor and ran directly into the his arms, as if he missed him a lot.
This sponsor shares,
"I am surprised by Pierre's reaction. It really touches me, and I can see that there is a change in his life. We can no more say that this boy is a poor one."
The coordinator of the child development center, Nathalie also testifies,
"Pierre is one of the leaders of his class now. He likes playing football with his mates and he is one of the children I most encourage at the child development center."
Many children are like Pierre. They do not have the opportunity to express themselves, so they do not have confidence in themselves. If no one helps them discover their potential, they will grow up being shy and timid.
Pierre was not the only person blessed by his sponsor's visit. At the time of this visit, Pierre's father was sick and in the hospital. He was suffering from a hernia and awaiting surgery.
When Pierre's sponsor heard that Pierre's father was in the hospital, he decided to visit him before going back home. This sponsor's visit gave Pierre's father strength and courage.
As for Pierre's mother, it was difficult to express the joy of receiving a visitor at a moment when it seemed like everything was hard and there was no way out. This sponsor's visit strengthened the hearts of Pierre and his parents. He tells us,
"I saw children in the bushes in Africa that do not even smile. But all the children I met here at the child development center are smiling. They are happy and they do not look like poor children. Compassion is doing something wonderful. I really appreciate what the ministry is doing. I think every sponsor should be able to visit his sponsored child."


text: I have a 4 week old, and I have to start pumping so that my husband or mother can occasionally give my son a bottle. When is the best time to pump in order to provide one bottle a day, to start? How do you schedule pumping/feeding sessions? Is it ok if I pump only a few days a week? Do you just pump right into the bottles and then dole out the ounces as needed?


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Childbirth itself has not changed at all! Babies are still born today in the same way that that they have been born for generations. But many things associated with childbirth have changed, including:
These factors have greatly changed women's childbirth experiences.
Today, a woman having a baby in an industrialized nation can reasonably expect that both she and her baby will have a healthy journey through pregnancy and birth. Childbearing is generally safe and does not represent illness or disability. A hundred years ago, many women faced childbirth with some fear because they knew of a mother or baby who had died. Today, however, there is some expectation that changes in childbirth technology not only minimize risks that might have led to death or disability a century ago, but promise a perfect outcome.
Additionally, in many parts of the world today, women can plan their pregnancies and tend to have fewer children than a century ago. This has created a culture where each pregnancy and baby generates intense attention.
Expectations of pain management have also changed. One hundred years ago, most children throughout the world were born at home. Although many factors contributed to the movement of childbirth from the home to the hospital, one important reason for this change was the development of pain-reducing childbirth anesthesia, which was only available at the hospital.
When childbirth occurred in the home, pain management was dependent on the skill of a woman's midwife or her family in helping her through childbirth. In the late 1800s, the labor analgesic "Twilight Sleep," a combination of morphine and scopolamine that both relieved pain and caused women to forget most of their labor and birth, became available in the hospital. At first, this option was only available to wealthy women who could pay for hospital care, but women's rights activitists advocated its availability for all women.
There were problems, however, with forms of dense anesthesia for childbirth. Women who were heavily medicated had difficulty communicating and difficulty pushing. Forceps and cesarean sections were often necessary to complete the birth. Babies who were born to heavily medicated women were born sleepy, with a decreased drive to breathe, and often needed resuscitation.
The development of spinal anesthesia, known in the mid-20th century as a "saddle block," helped relieve the pain of delivery, but often left women unable to push, again necessitating forceps deliveries. Anesthesiologists have continued to refine spinal anesthesia techniques, and in most Western hospitals today, many women may choose to have some form of epidural or spinal anesthesia for birth. Risks and benefits of these techniques are more fully discussed in the topics Why Should I Consider a Holistic Approach to Pregnancy and Childbirth? [1] and What Factors Influence the Normal Progression of Labor? [2]. As a culture, it appears that women have become more interested in a pain-free labor experience.
During the 1950s and 60s, women became more aware of the problems associated with heavy anesthesia during labor. Dense anesthesia had negative effects on women and their babies, and left women unable to play a role in their own care and that of their babies. Control of childbirth shifted from women (the birthing mother and her midwife), to the physician, (generally male at that time). The growing women's movement drew attention to this power change and set the stage for the natural childbirth movement. There was a strong sentiment that women, not their healthcare provider, should be in charge of the labor experience.
At first glance, the natural childbirth movement may have seemed a step backward in terms of comfort in labor and birth, but several advances had been made in non-medicinal methods of pain relief. Early proponents of natural childbirth (Dick-Read, 1943; Karmal, 1959; Lamaze, 1970; Leboyer, 1975; and Bradley, 1978) developed programs to prepare women for childbirth that included relaxation, patterned breathing [3], hypnosis [4], and water immersion. Encouraged by the work of these early experts, women began to reclaim their autonomy in the birth process.
Additionally, advances in medical treatment of pain have resulted in pain management techniques that are safer and less disruptive to the process of labor than earlier methods had been, although these are still not risk free.
The Additional Readings include recent and available works from childbirth experts with the most up-to-date methods of holistic pain management, and also include the classic works of the natural childbirth pioneers. Current pain management methods are discussed more fully in the topics What About Pain? [5]and What About Childbirth Classes and Birth Plans? [6]
During the 20th century, childbirth shifted to the hospital for several reasons:
Childbirth has remained in the hospital for reasons that are largely economic.
Throughout time, midwives have provided the majority of maternity care around the world, however, the late 1800s and early 1900s represented a time of change. The development of forceps in the mid 1700s, which were only used by physicians, introduced the doctor to maternity care.
Physicians were called to births when progress was slow or there were other problems, and thus their introduction to childbirth was in problem situations where the outcome was often poor.
At the same time, the medical profession was shifting its professional basis. Organized schools of medicine replaced apprenticeships as the preferred method of learning and obstetrics was included as an area of study.
Physicians in the U.S. organized the American Medical Association in 1847, which sought to promote the wellbeing [7] of its profession. For the first time, under the influence of the AMA, states passed laws regulating who could practice medicine. In general, this was a benefit to healthcare consumers, as it helped keep unqualified people from claiming to practice medicine, and it lead to the accreditation of medical and other professional schools. However, in the early 1900s these laws nearly put an end to the practice of midwifery as physicians sought the "business" of caring for pregnant women, using the medical practice acts to limit the activity of midwives. (A busy rural midwife in the early 1900s was estimated to make $678, compared to the estimated physician's salary at the time of $730, thus maternity care was a lucrative practice to seek!)
Physicians and hospitals also recognized that if a positive relationship was established with a pregnant woman, it would influence where she sought care for herself and her family for a lifetime. This provided another motivation to seek pregnant women as clients and is still a motivation today.
Beginning in the early 20th century and continuing today, hospitals recognized that they could gain income from providing services as well as providing a place to give birth. Epidural or spinal anesthesia, labor inductions, cesarean sections, even the placement of IV lines are a source of additional revenue for both the hospital and the practitioners involved (physicians, midwives, and anesthesiologists). From the perspective of the hospital, a low-intervention natural childbirth is not the most financially profitable.
The system of healthcare in the United States has changed dramatically over the past century. At the turn of the last century, people paid for their healthcare from their own pockets. As employer-provided health insurance and public health insurance programs such as Medicare and Medicaid developed, women's access to healthcare improved, but the cost of healthcare has increased at a rate well above the rate of increase in our incomes.
Most individuals now receive their health insurance through a managed care program of some sort, either individually purchased, employer, or government provided. A managed care program attempts to balance access to quality care with controlling healthcare costs. Managed care has introduced some key changes for women seeking prenatal care, among them:
Medical liability has also had an impact on current prenatal care and birth. The liability insurance premiums for providers of obstetric care are expensive and so is being sued. Consequently, practitioners seek any legal protection they can find. Following the standards of care established by the American College of Obstetricians and Gynecologists (ACOG) may offer some protection from liability. Practitioners feel more protected if the standards are cautious, even if they are not well founded in research. However, this may lead to an overuse of birth technologies.
A typical physician-attended hospital birth today looks very little like a home birth of a century ago. The past century has brought numerous advances in childbirth technology, including how the baby's wellbeing is monitored, tests and procedures during pregnancy, and birth practices.
The baby's wellbeing can be assessed by several methods:
The American College of Obstetricians and Gynecologists (ACOG) has outlined specific protocols for monitoring the heartbeat of a baby during labor and specific criteria have been developed for evaluating the heart rate. The ACOG protocols reflect research that shows that there is no benefit for low-risk women in using continuous monitoring as opposed to listening to the baby's heart rate intermittently. Moreover, continuous monitoring limits a woman's mobility and her ability to assume positions of comfort. If there is no remote telemetry monitoring available, she may be unable to walk or to use a shower or tub. Continuous monitoring has also been associated with an increase in other interventions, such as forceps, vacuum extractors, and cesarean section, without evidence of benefit to the baby.
Despite this evidence and the support for intermittent monitoring by the ACOG protocols, most laboring women in the hospital today are monitored continuously throughout their active labor. As a result, many labor nurses have grown so accustomed to continuous monitoring that they are unfamiliar with the option of intermittent monitoring.
Let's consider some tests and procedures physicians and midwives use to promote the health of the mother and baby. Providers generally offer women an array of screening and diagnostic tests during their pregnancy. (A screening test identifies an increased risk of a problem. A diagnostic test diagnoses the problem being considered. For example, the prenatal Quad Screen may identify a woman as having an increased risk of having an infant with Down Syndrome, but does not provide a diagnosis. The diagnosis can only be made with an amniocentesis).
It is now possible to identify more problems and risks earlier in pregnancy than ever before. This means that woman and their families have more decisions to make. For each offered test or procedure, women must decide if they want the test, and if so, what they are willing to do based on the results. For some women, the increased options for prenatal testing may lead to an increase in anxiety. All pregnant women desire a healthy baby, and to receive test results during pregnancy that indicate a potential problem leads to increased stress.
One perspective that may be helpful is to consider if the prenatal testing offered will be useful in making subsequent decisions. Some women don't want specific testing, because the information would not change what they plan to do. Some women want all the available information to help them make plans for potentially caring for a child with a disability, or to help them make a decision regarding pregnancy termination.
A full discussion of all of these tests available during pregnancy is beyond the scope of this module, but they are briefly outlined in this short guide to tests [8].
Ginny was offered first trimester screening to identify if she was at an increased risk of having a child with Down Syndrome or other chromosomal problems. After considering the screening tests available, and the follow-up tests that would be recommended if the screening tests indicated a problem, she and Charles decided that they wanted to be prepared if they had a child with chromosome problems, but she was not willing to take the small risk of miscarrying a normal child that could happen after amniocentesis. Her screening tests showed that she was at no greater risk of having a child with Down Syndrome than other women her age. Ginny and Charles felt relieved, but they understood that the potential for having a child with chromosome problems still existed.
Several birth practices have also changed in the past 100 years. Although cesarean sections and forceps were used early in the 20th century, their frequency was low. Today, the cesarean section rate is approaching 30% in the United States. A very recent trend is the elective cesarean section, that is, a cesarean section done without a current medical indication but that might potentially prevent future problems such as incontinence.
The development of the vacuum extractor has decreased the use of forceps, although both are still used frequently. Inductions of labor are becoming increasingly more common, and today, an estimated 40% of all women are induced, despite estimates that only 10% of women need to be induced for a medical reason.
Fortunately, some birth practices introduced in the past century, such as shaving a woman's pubic hair or routinely cutting an episiotomy, have been shown ineffective and discontinued. However, other practices, such as the routine placement of an IV, permitting a laboring women to have only ice chips, and not allowing her to use a tub if her bag of waters has broken, have continued to be a standard of care, even though not supported by research.
What is clear from the research is that although technological interventions may be helpful in many situations, their routine use for all pregnant and birthing women is not warranted.
The good news about having a baby today is that a wealth of information is readily available: from your provider, on the web, in bookstores, and at the library.
Medical ethics have also changed. The paternalistic and well-meaning "doctor knows best" attitude of a century ago has been replaced with a respect for the autonomy of the birthing woman and an understanding that all women must be provided with information and give consent before medical treatment.
Most midwives and physicians have a strong desire to do just that. However, a few providers although well-meaning, might provide fear-based, limited information, particularly if a woman is identified as being high-risk. Imagine being told, "unless you have this procedure, your baby might die" without additional information about the actual likelihood of death or disability, or alternatives to the procedure. How would you respond in such a situation? Fortunately, these practices are rare, and, even for women who have identified risk factors, many options and alternatives remain available to her during pregnancy and childbirth.
It is important to discuss any proposed tests, treatments, or interventions with your midwife or doctor. For many women, this is challenging. Think about the last time you had a talk with an authority figure, or someone whose area of expertise was different from your own. Chances are you found it a bit intimidating. Now add to this the challenge of having such a discussion during labor, a time when women may feel especially vulnerable. Clearly, the discussion of childbirth choices should begin during the prenatal period.
With this in mind, research prospective plans of care or treatment options, ask informed questions, and expect to be a full participant in decision-making during your pregnancy and birth. Information and discussion can help you identify when childbirth technology might offer the best outcome for you and your baby, or when a less technological approach would be more appropriate.
Lorinda and Marcus moved to a new town early in Lorinda's pregnancy. They knew that they wanted to find a provider who involved them fully in Lorinda's prenatal care and who would support their choices in holistic and alternative healthcare measures. They also knew that they wanted a provider who did not routinely induce labor, in a birth center where waterbirth was an available option. The first midwife that they saw in their new town supported their holistic choices, but did not offer waterbirth. However, she helped them find a midwifery practice that did include waterbirths.
[1] http://www.takingcharge.csh.umn.edu/why-should-i-consider-holistic-approach-preg
[2] http://www.takingcharge.csh.umn.edu/what-factors-influence-progression-childbirt
[3] http://www.takingcharge.csh.umn.edu/explore-healing-practices/breathwork
[4] http://www.takingcharge.csh.umn.edu/explore-healing-practices/clinical-hypnosis
[5] http://www.takingcharge.csh.umn.edu/what-about-pain
[6] http://www.takingcharge.csh.umn.edu/what-about-childbirth-classes-and-birth-plan
[7] http://www.takingcharge.csh.umn.edu/glossary/3#term45
[8] http://www.takingcharge.csh.umn.edu/node/657
[9] http://www.takingcharge.csh.umn.edu/our-experts/kathryn-leggitt-rnc-ms-cnm
[10] http://www.takingcharge.csh.umn.edu/our-experts/deborah-ringdahl-dnp-rn-cnm
[11] http://www.takingcharge.csh.umn.edu/activities/sample-birth-plans
[12] http://www.takingcharge.csh.umn.edu/activities/effective-birthing-positions
[13] http://www.takingcharge.csh.umn.edu/activities/questions-your-midwife-or-doctor
[14] http://www.takingcharge.csh.umn.edu/activities/questions-your-birthplace
[15] http://www.takingcharge.csh.umn.edu/activities/holistic-pregnancy-affirmation


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Honolulu Mayor Kirk Caldwell had five main priorities in his inaugural State of the City Address on Wednesday.
Caldwell started with restoring city bus service on Oahu. The first round of bus route restoration started in March and five more routes are scheduled in May. The restoration is expected to be completed in August.
"I've dedicated 3.5 million dollars in my budget to cover this priority, and we are going to better integrate TheBus into the overall City plan for transportation services," said Caldwell.
Caldwell says 43 percent of city roads on Oahu are in poor condition. That's why he is proposing to spend $150 million annually repaving 300 lane miles per year over the next five years.
"On this schedule, we will fix the majority of Honolulu city roads that are in bad condition, and I will start a repavement preservation program of the roads that are in 'good' condition starting in July," said Caldwell. "In the last seven years, the city paved about 1,000 lane miles. Those roads will last five to 10 more years with proper maintenance, which I am committed to do."
The mayor pointed out the critical part the city's sewer infrastructure plays in our lives.
"If we don't have enough sewer capacity, the city cannot approve new development projects, large or small, across the island, which will have a negative impact on our growing construction industry," said Caldwell. "The City agreed to complete 477 projects to comply with the consent decree, which we entered in December 2010. So far, we have completed 297 or 57 percent of those projects, and we have met every single project due date."
The city has 180 project remaining including the Kaneohe/Kailua Gravity Tunnel and the Secondary Treatment Facilities at Honouliuli and Sand Island.
Caldwell is putting $11.8 million to repairing and improving park facilities, with special attention to restrooms, playground equipment, lighting and recreational facilities. He will also be putting in $1.3 million for maintenance equipment.
"To me, all of the great cities of the world have great parks -- Central Park in New York City, Hyde Park in London, Stanley Park in Vancouver, Luxembourg Gardens in Paris, Ueno Park in Tokyo to name just a few," said Caldwell. "I want Honolulu to have that distinction, too."
Part of Caldwell's mayoral campaign was to "Build Rail Better." It's also a part of his mayoral address.
"HART completed its Archaeological Inventory Survey two months ahead of schedule, and is ready to start construction in West Oahu later this year," said Caldwell. "If we want to maintain public confidence in this project, we need to make improvements based on community concerns, and demonstrate fiscal responsibility, and transparency, at every phase."
Caldwell maintained that public transportation will work hand-in-hand.
"Together, rail and bus will serve as critical components of our transportation system for generations to come. It's not rail vs. bus. It's rail and bus," said Caldwell.
The mayor also said the problem of homelessness is an issue that needs immediate attention.
"As you know, Bill 7, a bill addressing nuisances on public sidewalks, is progressing through the City Council," said Caldwell. "If this bill passes, I will sign it."
Caldwell is also focusing on housing the chronically homeless as quickly as possible as the first step toward recovery.
The mayor ended with a commitment to take care of our kupuna.
"There are so many ways that we can make things easier for seniors," said Caldwell. "I want to improve the HandiVan service, and I want to look at the way we approve permits for home improvements to help aging-in-place."
Click here for a full transcript of the State of the City Address.
KITV4 News will have more on the mayor's address tonight at 5, 6 and 10 p.m.


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|Photo courtesy UnofficialSquaw.com/Flickr
The White House last week honored 12 people from across the United States who are taking a leadership role in their communities on climate change.
The Champions of Change [3] recipients are working in fields as diverse as military contracting, coastal restoration, and agriculture, but what ties them together is their belief in the importance of taking action on climate change.
One award winner, snowboarding pioneer Jeremy Jones is the founder of Protect Our Winters [4] (POW), an advocacy group that is mobilizing the winter sports community to take action on climate change. Skiers and snowboarders are witnessing the effects of climate change firsthand as snowfall patterns shift and snow season gets shorter. These changes also haven't escaped the attention of companies like the Aspen Skiing Company, which signed the Ceres' "Climate Declaration" [5] calling for Congress to act on climate change. POW's success in getting the message out to the winters sports community highlights how a personal, impacts-related [6] climate message [7] can resonate, especially when there are solutions available [8] to address the problem [9].
Also receiving recognition was Fred Yoder, a fourth-generation farmer involved with the 25x'25 Alliance [10], a group that promotes renewable sources of land-based energy. Yoder noted that farms have a huge potential to both reduce the greenhouse gases contributing to climate change and build resilience to the impacts we cannot avoid.
|Photo courtesy USDSgov/Fiickr
For example, improving soils can both store more carbon and trap more moisture in the ground. Farmers also adopt practices to make their crops more resistant to drought, which is expected to become an increasing threat in some areas due to climate change. Although the recent drought [12] was far worse than the last major drought in 1988, new farming practices have vastly improved yields, sparing farmers significant hardship.
Adapting to the impacts that are unavoidable and reducing greenhouse gas emissions to limit future risk are complementary actions that will both be needed to successfully tackle climate change, and the Champions of Climate demonstrate that there are opportunities for individuals of all backgrounds to take action. [13]
[1] http://www.c2es.org/blog/huberd
[2] http://www.c2es.org/docUploads/change-photo-1.jpg
[3] http://www.whitehouse.gov/champions
[4] http://protectourwinters.org/
[5] http://www.ceres.org/bicep/climate-declaration/
[6] http://www.c2es.org/blog/huberd/how-climate-change-amplified-sandy%E2%80%99s-impacts
[7] http://www.c2es.org/blog/huberd/increasing-extreme-weather-costly-many-ways
[8] http://www.c2es.org/blog/seidels/us-should-act-now-reduce-short-lived-pollutants-damaging-climate
[9] http://www.c2es.org/blog/greenwaldj/rggi-changes-help-both-environment-business
[10] http://www.25x25.org/
[11] http://www.c2es.org/docUploads/change-photo-2.jpg
[12] http://www.c2es.org/science-impacts/extreme-weather/drought
[13] http://makeanimpact.c2es.org/


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A month ago I gave birth to my son with a c-section (hence, antibiotics for a week). Although I was planning to breastfeed him exclusively, we didn't start off well. He could not latch on and at the time I didn't even know he wasn't latching on. I kept doing what I was doing wrong, resulting to a hungry baby, bottles of pumped milk, injured nipples and a lot of crying for the both of us!
A week after the birth we had made some progress. I managed to get him to put most of the areola into his mouth and I felt the difference immediately. My cracked nipples started to heal finally and I was able to breastfeed him exclusively to avoid any further confusion. He's been feeding well, as often as he wants and putting on weight. A midwife who visited me and saw me breastfeeding confirmed that we were both doing fine. But... A few days later I started having pain in the areola of my right breast and a few bumps which went away after some gentle massaging. It hurt a lot when he latched on but the pain subsided while he was feeding, so I stuck it out. It was nothing compared to the nipple pain of the first days!
However, during the following days my nipples started feeling extremely sensitive and kind of raw. When breastfeeding I would feel a tingling sensation that was not painful but especially in longer feeding sessions it would become very uncomfortable. I could tell something was not right and yes, sometimes my nipples would look lipstick shaped afterwards - especially in the cross-cradle position, the football hold works always better for us. Moreover, I felt stabbing pains in my breasts and a burning sensation, like pins, in my nipples and areolas not just when breastfeeding, anytime really, e.g. when I cough, or even when I drink water!!
I suspected thrush even if the baby had no symptoms because of the antibiotics I had taken and the cracked, injured nipples which I nabbed with breast milk all the time during those first days. After talking to the pediatrician baby and I started taking an anti-fungal (miconazole) - it's been three days now. The stabbing pain has kinda subsided but the burning and the super sensitivity not really. I started wondering whether it's vasospasms because I do see my nipples change color sometimes, not particularly after feedings though. Their usual color these days is pink-red, like they are inflamed. I started using APNO as well and I hope it's OK to use it together with the miconazole.
Hopefully I will see some progress, although I really don't know if it's thrush, vasospasms or both! Can just the poor latching cause the burning and the super-sensitivity? I definitely want to work on the latching, it seems that my baby is content with our current style and just won't open his mouth big enough when I bring him to the breast. Or maybe his suckling is not right, how can I work on that? I am planning to attend a local LLL meeting (in Athens, Greece where I live) but if you have any tips in the meantime about our latching problems and about my breast/nipple issues I would be grateful to read them.
Thank you and sorry for the long post!


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July 9, 2012
DOE alleged in a Notice of Proposed Civil Penalty that ASKO Appliances, Inc. failed to certify residential clothes washers and dishwashers as compliant with the applicable energy and water conservation standards. DOE regulations require a manufacturer (which includes importers) to submit reports certifying that its products have been tested and meet the applicable energy and water conservation standards. This civil penalty notice advises the company of the potential penalties and DOE's administrative process, including the company's right to a hearing. DOE sought a higher civil penalty due to a prior history of the same type of violation.


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By: Barb Belknap on December 31, 2012 - 4:38pm - Add new comment
We humans had a terrific Christmas this year. Thoughtful gifts. Great food. Happy grandchildren. Our daughter Amy and Olive, her Blue Heeler, came up from Seattle. The exception to the overall joy was Deacon, our reclusive generally weird black cat, who spent the holidays hiding behind the paint cans on a shelf in a dark corner of the garage. The area in front of the shelf is blocked with a blue plastic tub full of boat stuff, two emptied Kitty Litter buckets overflowing with golf balls, and our pickup truck.
By: Barb Belknap on December 24, 2012 - 10:41am - Add new comment
I love Christmas. I love the familiar rituals that I've followed for forty plus years. Around the 10th of December, Doug gets the big extension ladder out and props it up against the opening to the attic. One by one, he hands me the worn boxes marked "Christmas" out of the attic with their CDs, ornaments, knickknacks, and the crèche. Our live Christmas tree always comes from Glacier Gardens, but the wreath with the big red bow is plumped up with boughs from a convenient tree behind our house.
By: Barb Belknap on December 18, 2012 - 3:42pm - Add new comment
Dear Planning Commission members, I want to see the Planning Commission deny the Juneau Mercantile and Armory owners a permit to have fully automatic firearms for their customers to use. Given the horrific events in Connecticut where so many women and children were slaughtered with round after round of automatic weapon fire, I strongly urge you to not approve their use at Juneau Mercantile and Armory, the proposed gun range.
By: Barb Belknap on December 12, 2012 - 11:15am - Add new comment
All this snow reminds me of the one and only time I used a snowblower. Fortunately, no one died. That particular winter, Doug, the Official Snowblower, was going out of town, but snow doesn't take a hiatus so he showed me how to start it. He demonstrated the basics of maneuvering it around, cautioned me to be careful, and left. Doug always clears the whole driveway and the berm, and often takes care of the neighbor's berm while he's at it.
By: Barb Belknap on December 7, 2012 - 2:13pm - Add new comment
Today is Pearl Harbor Day, the day we commemorate the air strikes on Pearl Harbor, Hawaii, and the invasion by the Japanese. My mother's first cousin, Harold Arneberg, died on the U.S.S. Vestal. My mother's beloved and only brother, Bill Collins, was killed during the war. Forever young, his photo was always in a prominent place in our home.
By: Barb Belknap on November 30, 2012 - 9:49pm - Add new comment
The November 11th issue of the Empire had an article on page A9 with the headline:"Vatican digs in after gay marriage advances". A shorter article next to it declared, "Pope resurrects Latin with academy to boost study." I tore the page off, folded it, and set it on my desk, where it has languished for almost three weeks.
By: Barb Belknap on November 23, 2012 - 6:28pm - Add new comment
by Barbara Belknap
We came home with a heavy bag of goodies from the 2012 Juneau Public Market. When we got there around 2:00, the line was moving quickly. Once we had our bright red tickets, Doug and I split up at the double doors so we could check out our favorite vendors and browse at our own speed.We agreed to meet back in the entry area at 4:00.
By: Barb Belknap on November 21, 2012 - 4:12pm - Add new comment
"Gratitude unlocks the fullness of life. It turns what we have into enough, and more. It turns denial into acceptance, chaos to order, confusion to clarity. It can turn a meal into a feast, a house into a home, and a stranger into a friend." Melody Beattie
I want to wish everyone a happy Thanksgiving. Holidays, particularly Christmas and Thanksgiving, bring back memories of family gathered around the table. We've sat at tables where two or three tables were placed end to end, and covered with different tablecloths and different sets of dishes.
By: Barb Belknap on November 19, 2012 - 3:32pm - Add new comment
I'm sifting through the business cards, notes, and notations from the 3rd Vision2020/Drexel University Congress in Portland, Oregon. I got home late yesterday after a long day of flying broken up by a wonderful lunch date with our daughter in Seattle.
Vision2020 is an ambitious program to achieve equality for women in five areas by the year 2020:
* Increase the number of women in senior leadership positions in American life to reflect the workforce talent pool and demographics;
By: Barb Belknap on November 16, 2012 - 3:10pm - Add new comment
Over 100 women, two from each state, spent all day yesterday (Nov. 16) at the third annual Vision2020/Drexel University Congress in downtown Portland.
Portland welcomed us with open arms and enthusiastic support for the initiative's goals. Once I get home to Juneau, I'll write more about the goals, progress made, and some of the great work women are doing around the country.
Click Here to View This Weeks Listings of Homes in Juneau
Juneau Empire ©2016. All Rights Reserved.


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The Friends of the Mill Valley Library present a series of Monday Night at the Movies events. This month's theme: Films of Ian McKellen.
Cold Comfort Farm (1995)
Monday, December 2nd @ 7:30 p.m. Cold Comfort Farm is a 1995 made-for-TV movie based upon a comic novel published in 1932 by English author Stella Gibbons. It parodies the romanticized, sometimes doom-laden accounts of rural life made popular at the time. Gibbons was working for the Evening Standard in 1928. Following the death of her parents, the book's heroine Flora Poste (Kate Beckinsale) finds she is possessed "of every art and grace save that of earning her own living." She decides to take advantage of the fact that "no limits are set, either by society or one's own conscience, to the amount one may impose on one's relatives," and settles on visiting her distant relatives, the Starkadders, at the isolated Cold Comfort Farm in the fictional village of Howling in Sussex. The inhabitants of the farm – Aunt Ada Doom (Sheila Fry), Flora's cousin Judith (Eileen Atkins), Judith's husband Amos (Ian McKellen), and their extended family and workers – all feel obligated to take Flora in to atone for an unspecified wrong once done to her father. As is typical in a certain genre of romantic 19th-century and early 20th-century literature, each of the farm's inhabitants has some long-festering emotional problem caused by ignorance, hatred, or fear, and the farm is badly run. Flora, being a level-headed, urban woman, determines that she must apply modern common sense to their problems and help them adapt to the 20th century. Doors open at 7:00. This series is sponsored by The Friends of the Mill Valley Library. For more Programs and Events at the Library, see the Library Events Calendar.
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21st Annual Southeast College Conference, sponsored by Senator Ricardo Lara
• Students – Meet college recruiters, learn how to prepare for college and apply for scholarships. Information on college opportunities for AB540 students, including deferred action and the California Dream Act Legislation will also be available.
• Parent and Family Members – Learn how to support your student's education and what you can expect from the college experience.
• Everyone – Stop by to discuss legislation and state government programs that can help you pay for college.
©2016 Hispanic Scholarship Fund All rights reserved. HSF Press | Privacy Policy


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Jon Stewart's 47 mph…unfastball?
Bubbe. I love you. You're a super Mets fan, so I love you even more. And I certainly didn't boo you! But don't quit that day job just yet, okay? (Stay tuned here for the YouTube footage at the end, which is PRICELESS. Especially the last one, of Willie's and Rick Down's reactions.)
NLCS Game 2 First Pitch (Zoe's pics from the game and Diamondvision):
Jon Stewart greets the screaming crowd:
Jon Stewart's (heart-tugging) reaction to being booed. (Awww.)
Hugging and posing with Sandy Alomar.
I had a feeling Jon Stewart would mention his less than awesome first pitch on The Daily Show last night, but I had no idea to what extent he'd show all the video footage. It was hilarious, and here are the highlights for you on YouTube. (Sorry my camera doesn't take better film off my TV! Oh well.) :
1. Jon Stewart throws first pitch.
2. Jon Stewart on the Shea reaction.
3. The full extent of the booing.
4. Willie and Rick Down's reactions. It's easy to miss Rick Down's "Hey! We got to bring in George W. Bush!"
LET'S DO THIS TONIGHT, METS! The Team. The Time. The Getting The Cardinals Where They Sleep.
1 Comment
Wow… Jon's 47 mph heater makes my 65 mph cheese look pretty good lol.
Let's go Glavine and Let's Go Mets!
~ Eddie @ Willie Ball


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"The work of Catholic Answers was instrumental in bringing me back to the Church. With the help of God's grace, I was then able to help bring my wife back too. Keep up the good work!"
~ Daniel, Harrogate, Tennessee
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"Without Thy presence, nought, O Lord, is sweet,
No pleasure to our lips can aught supply.
Whether 'tis wine we drink or food we eat,
Till Grace divine and Faith shall sanctify."
~ Prudentius, a 5th century Christian poet, from his Ante cibum, describing the Christian practice of "saying grace" before meals.