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Tuesday, May 30, 2006
The Age of AIDS
When I was a young art student in Philadelphia in the early 1980's, I came to personally know a number of gay men who began to exhibit symptoms of massive weight loss, strange pneumonia-like infections, and purplish splotches on their faces and arms. The idea of a "gay cancer" attacking the male homosexual community gained ground quickly in those early years, and due to my connection to the arts community and its large gay subculture, I was witness to the beginnings of the devastation that was to follow.
Looking back, I clearly remember a gay acquaintance of mine---a fellow painter---who made it very clear that he wanted me to be his lover. Never having had romantic feelings for men, I politely rejected his ardor, and our acquaintance never amounted to much, although we had a few mutual friends and would see one another at various art openings around the city. Several years later, before I left Philadelphia, he died a miserable death, riddled with Kaposi's Sarcoma and pneumonia, apparently having wasted away to a mere shadow of his former robust self. It's only now that I realize how profoundly life-altering a choice it would have been if I had entertained his offer of companionship. At that time, heterosexual infection was still relatively unrecognized, and although I had dodged an enormous bullet, the risks for young adults in the early and mid-80's would only grow.
A few years later, as a newly-trained massage therapist, I leapt at the opportunity to volunteer my services at a free holistic AIDS clinic in a relatively small New England city hit hard by the epidemic. Both gay men and IV drug users were affected most profoundly, although it was mostly only the gay men who flocked to the clinic for free medical advice, acupuncture, massage, support groups, and a place to feel at home. With my wife as a counselor, we both subsumed ourselves in this community which embraced everyone who walked through its doors. Free of the professional boundaries of a medical practice, we partied together, had meals together, raised money, created friendships, and developed a small network of interconnected lives who all worked tirelessly to improve (and possibly prolong) the lives of our affected brethren. Men dominated the clientele, but there were women as well, and the mix was enlivening and exciting. We were part of something great. I remember dinners, healing sessions, fund-raisers, Halloween parties with over-the-top drag shows, and funerals galore. Funerals. Memorial services. And more funerals. And more. Mary and I practiced Reiki on one of our dear friends as he lay on his deathbed. This kind soul, who had been at the top of his game in the publishing world in New York City, who would hum show tunes as I massaged his slowly wasting frame, died in the middle of the night with his beloved sister holding his hand, people chanting and praying around his bed. We were not there for his death, having gone home to tuck in our young son in the big haunted house where we lived at the top of the hill.
Now, in my current professional role as a nurse, clearly deeply affected by my earlier life experiences, I still marvel at the insidiousness of the virus, its ability to mutate and gain resistance to powerful medications, and its clear agenda to infiltrate every walk of life, nationality, race, and religion. What was once "the gay cancer" has become the most lethal epidemic in memory, and its grip on Africa and Asia tightens like a noose with each passing year. While I may not work exclusively with patients with HIV or AIDS, I currently carry fifteen people on my caseload who are infected, and have probably lost half a dozen in the last five years. For every victory, there's a dismal failure. For every stellar patient who takes his or her meds like a champion, another can't seem to stay focused long enough to follow through. The city where I work has been violently attacked by the virus, and politicians' fears of a needle exchange program have furthered the epidemic by tacitly allowing dirty syringes to pass from hand to hand.
As a Baccalaureate nursing student several years ago, I and a few classmates wandered the back streets of another devastated town under the guidance of a heroin addict in recovery, visiting the places where junkies shoot up, handing out condoms and bleach kits, preaching the gospel of clean needles and safe sex. Much to our professors' dismay, we held a health-fair at a local drop-in center for IV drug users, teaching them clean injection technique, how to sterilize needles, skills which could prevent infection with HIV, not to mention dangerous abscesses of the arm from poor injection technique. It's called harm reduction, and we did it well, if not a little clumsily. Did we save lives? No one can say. But one piece of information can go a long way, and I like to think that the effects of our work may live on in some child somewhere, whose parent used those techniques to avoid infection and thus give birth to an uninfected child. How I hope that that may be the case.
So, my friends, take a moment to acknowledge this anniversary, whether you have known someone infected with the virus or not, whether you work with infected individuals or not, whether your family has been touched or not. It is a passage in human history worth pausing for, and a time for even a brief reflection at this historic time.
May all beings be happy. May all beings be free from suffering.
Monday, May 29, 2006
Paradox Now
Watching a film last night, Paradise Now, I was reminded how many people in the world live in environments of constant stress and trauma, with leisure and stress relief something of an unattainable panacea. In the film, two Palestinians in the West Bank are chosen for a suicide mission in Tel Aviv, and each one must grapple with his conscience. Aside from the socio- and geo-political implications of the film, what I took away from it was a sense of how people all over the world live in situations in which respite from stress---often a level of stress which is trauma-producing---is often not an option. In Darfur, Palestine, Congo, Iraq---life is interwoven with the constant and relentless threat of death or dismemberment. On many of the streets of rural and urban America, hunger and poverty rule the day. How many American children go to bed hungry each night?
I'm struck by the paradox of reveling in my long weekend, recovering from the stress of full-time, well-paid work, replete with comprehensive health insurance and relative job security. Of course, it's a given that stress is relative, and there's no question that I deserve rest and renewal within my middle-class bubble. However, in the larger scheme of things amidst the general tumult of the world, my struggles to lose a few pounds, decide if we can afford having someone clean our house twice a month, or how long we can go on vacation this summer take on a somewhat anemic pallor. Clearly, perspective is key in this moment, and one must not lose sight of one's place in the puzzle, playing with the deck that's been dealt. Middle-class guilt for one's luxuries serves no one, but at the same time blinders to others' plight serve no one as well.
The conclusion which I draw this morning is that awareness of one's relative priviledge is key, while mildly indulging one's needs is not evil or disingenuous, as long as one retains a view of the larger picture, using that position of relative priviledge to positively effect the lives of others.
Some rhetorical questions:
Does the quintessential "wounded activist" serve anyone through his or her self-denial of pleasure? Does not the blind purchase of goods at Wal-Mart made in Chinese sweatshops help to perpetuate the globalization (and Wal-Martization) of the world? Does simply doing one's work and living a balanced and non-ostentatious life improve the lives of others indirectly? Do political bumper-stickers with catchy slogans preclude the need for real political activism in one's life? How do my actions from day to day truly effect the lives of people in Darfur, Palestine, South Central LA, or Basra? Does my purchase of a new refrigerator negatively impact some individual life somewhere in the world? What do my purchasing habits say about me? How does the sum of my actions define me in the larger scheme of things? Am I doing enough? Am I walking my talk? Where is my energy best spent? Am I more blinded by my priviledge than I can truly see?
I realize as I write that these are not necessarily the words of a person embracing a national holiday and paid day off with complete equanimity. I'm choosing to not live my life like a blind and ignorant bull in the china shop of the world. I want to acknowledge the paradoxes inherent in being a middle-class white American with full-time work, health insurance, my own home, and the luxury of time and material well-being. One must accept where one is, change that which one chooses to change, and live life according to a chosen path. I simply find it necessary to periodically examine that path, take stock of my position in the wider world, and determine if I'm truly living the life that I desire. Blindess is an option, but I choose today to re-open my eyes.
Friday, May 26, 2006
Attrition and Addition
Just as I'm beginning to digest this particular co-worker's departure, celebrating her new chapter of life with a group dinner out on Wednesday and a cake and gifts today, yet another colleague announced her imminent departure in 14 days, followed by yet another whose departure date is set distantly for September. Just as our office is undergoing a major shift of responsibilities and practice coordination, some of the cogs are removing themselves from the wheel, and we will soon all be reeling from the effects of such personnel loss. Of course, we have lost many others over the years as well, living to tell the tale each time. But each time a member of the team leaves, worries surface that the new replacements won't "gel" as well, that the sense of family and connectedness will be undermined, that what we have worked so hard to create will feel different, less intimate, less cohesive. While I am generally one who welcomes change, stability in a stressful workplace is key to success and satisfaction, and each change which threatens stability does not necessarily bode well for the future.
On the bright side, someone of whom I am exceedingly fond and with whom I worked within another agency some ten years ago was just hired to join our team in a somewhat administrative capacity. We will not be sharing patients, per se, and she will not be directly involved in my day to day practice, but her presence in the office is a "good fit" and brings some fresh energy and ideas to the fray.
So, attrition and addition were foremost on my mind today, even as the calls and pages, unannounced visits and constant multi-tasking pummeled my tired brain and body. Now a long three-day weekend awaits, Friday night relief seeping into my bones like a nectar.
Wednesday, May 24, 2006
Private Hell
After she left, the NP and I looked at each other and shrugged our shoulders, giving in to the notion that we were powerless to change her life, powerless to keep her with us when she didn't want to be kept, and frustrated that so many people live in such isolated and private purgatories.
Other personal purgatories revealed themselves to me today as well, as they do most every day. We are witnesses to suffering, as I have said before, and it is not our job to fix, to repair, to alter the course of others' lives by sheer power of will. There are forces at work much larger than us against which we have little transformative power. The best we can do is open doors and illuminate pathways, cajoling and teasing our patients towards different choices and better alternatives.
Coming back to my small town with good schools, excellent infrastructure, and tax dollars hard at work for the benefit of middle- and upper-middle class families, I realize that I can't change the dynamics and machinations of inner city life. There are slum lords, corrupt officials, drug dealers, gangs, organized crime, institutional racism and economic apartheid which all contribute to the plight of the poor. It is all of our responsibility to turn that tide, but in the course of a day slogging through the swamps of chronic illness, poverty, and lives of desperation---be that desperation quiet or not---I at times lose sight of the benefit which my therapeutic interventions may have.
At times, I wish that I was one of those movers and shakers who takes on the system, challenges the status quo, and creates a new society from the ashes of the old. Alas, I am not so much of a leader, opting instead to do my work in the quiet of one-to-one interaction and therapeutic relationship, in the hopes that my work will have some small impact while others with a larger grasp of the global issues work to undermine the foundations of the larger framework which only serves to further oppress the oppressed.
Please forgive this rant. It is just a tip of the iceberg of the rage and sadness felt while witnessing first-hand the misery of those living in the belly of the beast---urban America.
Saturday, May 20, 2006
Greetings From Atlanta
Scenes from the day:
-Anxious couples rushing to catch their flights, babies and strollers flying everywhere.
-Security agents joking with passengers and being playful, returning a confiscated nail-clipper with a smile and admonition that it is contraband.
-A man on the subway who took a pack of Camel Filters from his shirt pocket and proceeded to do that ritualistic tamping down of the cigarettes by hitting the pack repeatedly against his palm. The look of utter concentration on his face as he performed this well-practiced ritual was intense to behold. He then held a cigarette between his lips as the train came to a stop. Perhaps he felt some nicotine seeping into his mouth through osmosis. Perhaps the taste of the cigarette between his lips was enough to mollify his craving for the time-being. I noted his barrel chest and spider angioma on his nose (small, red, broken capillaries) which spoke to me of years of hard drinking and smoking. His was a story with many fascinating chapters.
-At the top of the long escalator up to baggage claim in the Atlanta airport, there is an enormous and awe-inspiring mural whose centerpiece is a beaming African-American child with arms stretched joyously overhead, welcoming the visitor to this racially diverse city which was the birthplace of Martin Luther King, Jr.
Apropos of Mr. King, on Monday we will visit the tomb of this amazing man, and see the home in which he was born.
The warm embrace of the South and of family is soothing to my spirit today.
Wednesday, May 17, 2006
MRI for I & I
Ear plugs donned and padding stuffed around my head to cut down the noise, the table rose into the air and I was slid into the sarcophagus-like tube. The disembodied voice of the technician came over the intercom every so often to inform me how long the subsequent series of pictures would take. I guess this is supposed to be reassuring, but I found it annoying in terms of interrupting my meditation.
Each time the machine whirled into action, it would make a semi-rhythmic set of sounds---electronic, of course, but each one with a distinct tone. While it would be easy to be unnerved by the racket, my predilection for strange electronic and experimental music paid off in a big way. (If any of you've heard Matmos' CD, A Chance to Cut is a Chance to Cure, you know what I'm talking about. That CD is made almost completely from sounds recorded, sampled, and edited from various medical procedures such as liposuction surgery. Really. And it's still called music!) I approached each sound as an event, a sonic reality which presented itself for meditation and analysis. Each series of sounds and vibrations brought a new mental sensation and emotional timbre. As I listened intently, I even found myself hearing harmonics and other layers of sound which I was not sure were real or simply a part of my internal aural experience as the sensations entered my inner ear and traveled the cranial nerves into my brain. The permutations of sound were actually multitudinous amidst what could be experienced as a form of post-modern sensory torture. (Does the United States government employ MRI machines in its arsenal of interrogation techniques? They could consider it, but fans of electronic music and meditation would be strongly protected against ill effects. Attack dogs are so much more cost-effective, as is near-drowning and sexual abuse, but alas, that's for another blog....)
Anyway, despite what could be considered as infernal noise born of a Radio Shack in Hades, I experienced what turned out to be a quite peaceful time in that tube. Beyond simply learning a little more first-hand what patients experience in the maw of the MRI, I took advantage of this opportunity to have an interesting and thought-provoking aural adventure at the cost of many thousands of dollars by Blue Cross/Blue Shield. I should let them know how enjoyable it was and that I feel it was certainly money well spent, no matter the outcome of the actual exam. I'm sure they'd be thrilled (and subsequently increase my deductible).
Tuesday, May 16, 2006
Grand Rounds Comes Around----Again
Sunday, May 14, 2006
Mother's Day
Mother's Day Proclamation
"Arise, then, women of this day!
Arise, all women who have hearts,
Whether our baptism be of water or of tears!
"Say firmly:
"We will not have great questions decided by irrelevant agencies,
Our husbands will not come to us, reeking with carnage, for caresses and applause.
Our sons shall not be taken from us to unlearn
All that we have been able to teach them of charity, mercy and patience.
We, the women of one country, will be too tender of those of another country
To allow our sons to be trained to injure theirs."
"From the bosom of the devastated Earth a voice goes up with our own.
It says: "Disarm! Disarm! The sword of murder is not the balance of justice."
Blood does not wipe our dishonor, nor violence indicate possession.
As men have often forsaken the plough and the anvil at the summons of war,
Let women now leave all that may be left of home for a great and earnest day of counsel.
"Let them meet first, as women, to bewail and commemorate the dead.
Let them solemnly take counsel with each other as to the means
Whereby the great human family can live in peace,
Each bearing after his own time the sacred impress, not of Caesar,
But of God.
That a general congress of women without limit of nationality
May be appointed and held at someplace deemed most convenient
And at the earliest period consistent with its objects,
To promote the alliance of the different nationalities,
The amicable settlement of international questions,
The great and general interests of peace."
I enter this post in honor of Mothers everywhere, and in condolence to all Mothers who have lost children to war, famine, disease, brutality, slavery, and human frailty.
To paraphrase Robert Fripp, may our living honor our mothers and repay the debt of our existence.
Saturday, May 13, 2006
A Letter to My Students on the Occasion of Their Final Exam
Well, folks, here we are at the end of our nine months together, and I am truly sad to see you go. You've been a great class, and I've learned a great deal from all of you. As was said by some famous person, the roles of student and teacher are often reversed.
I wish I could affirmatively say that I have sufficiently prepared you all for the NCLEX, covering every detail that might confront you when you sit in front of that dreaded computer screen, but alas, it's not my place to say whether you're prepared or not, nor can I affirm that we did all that we needed to do. The fact is, we covered a great deal of ground but could never do it all in nine months no matter how hard we tried. It will now be up to each of you to prepare for that last major hurdle before you can officially enter the nursing profession.
That said, I want to leave you here with a few pieces of advice.
Nursing is called a "practice" because, in my opinion, it takes constant practice to be the best nurse you can be from day to day. As your practice develops, you need to be continually willing to learn and grow---both professionally and personally---or you'll stagnate. Continuing education credits are something that many of us dread fulfilling, but continuing education is crucial to staying abreast of what's new and different out there in the world. Medicine is constantly changing and evolving, and we need to evolve with it if we want to be up to date and savvy in our work. So, to that end, be interested in learning. When something doesn't make sense, look it up, ask someone, or try to discover more about it. Let your curiosity lead you to always learn just a little more. It's the exceptional nurse who's willing to ask why and then find the answer.
I can't emphasize enough that you must continue to increase your comfort with technology. By this I mean computers, the Internet, search engines, email, chat rooms, blogs, databases, spreadsheets, on-line research, on-line journals, etcetera. Many hospitals (and maybe nursing homes, as well) now employ laptop computers on wheels that the nurses must use for orders, notes, and other documentation. Some facilities are moving in the direction of electronic medical records (EMRs) and you have to be ready to deal with this reality. If you're already skilled and comfortable with some forms of technology, include this on your resume under the heading of "Skills". Potential employers want to know who can sit down at a computer and need only a little coaching to get started. If you have the ability to take some computer classes at MCDI or another school, take advantage of that opportunity as soon as possible. You can mark my words that being conversant with technology will only increase your ability to find a job you like, the caveat (remember that one, Lindsay?) being that lack of understanding of such information can be a professional liability.
There are many places on the Internet for nurses to surf for information and I want to point you in the right direction. As I may have mentioned in class, if you need to find something out about anything, go to Google and simply type in what you're looking for. I use it daily and have rarely been disappointed.
Medscape is a great free resource on the Web, and I recommend that each of you sign up. Just go to www.medscape.com/nurseshome. You can create an account and then come back as often as you like to look for articles, support, links to other sites, and updated information, as well as conferences and on-line CEUs. You can sign up for various Medscape email updates, or you can just check the site at your leisure.
Other sites of interest:
www.allnurses.com General nursing site
www.globeofblogs.com A blog registry site. Find blogs on nursing or anything
www.blogger.com A great way to start your own blog.
www.digitaldoorway.blogspot.com: my blog where I mostly write about my work, and link to many other medical and nursing blogs of great interest and variety.
I recommend you collect letters of recommendation from anyone you work with that would be willing to write one for you. Keep a file of these, and also ask those individuals if they'll serve as references for you when you apply for jobs down the road. Also, keep an updated resume on your computer at all times, changing it as necessary depending on the job you're applying for. After you accumulate more experience, you can have several versions of your resume on hand and you can target them towards different types of facilities.
Once you have some experience under your belt, start to look around and find out what facilities and agencies are hiring LPNs. Dialysis units, doctors' offices, schools, some VNAs---there are many places open to hiring LPNs. I know for a fact that ____________will hire skilled LPNs for their HIV/Mental Health, Pedi, and MedSurg teams. This is something to look forward to.
I know most of you would rather not think about it, but furthering your education is also something that you can consider. Being an LPN is great, but if you want to broaden the scope of your practice, consider eventually becoming an RN, if not a BSN. While it of course involves more loans, more studying, more sacrifice, and lots of work, it also involves greater ability to pick and choose your work environment, as well as larger paychecks. It is only food for thought, but definitely worth considering.
Nurses Eat Their Young
You may have all heard the phrase, "Nurses Eat Their Young", and I have heard a few stories from some of you who already have experienced the callousness and rigidity of some of those nurses out there. No matter how poorly you might be treated by some of those seasoned nurses, be careful to not repeat history when it's your turn to mentor someone new. I always try to be exceedingly kind and helpful to nursing students, because I remember that "there but for the grace of God go I". It was not long ago that I was in the same boat, and it's no fun when all you want to do is learn to do your job and someone seems to go out of their way to make you miserable while you try. If we each decide to break that cycle, many more novice nurses will stay in the profession and pass that kindness along to the next generation.
The Future
As your teacher, I feel a responsibility to be available to you if you do indeed need a letter, some advice, or another form of support over the next few years. Since I don't plan to continue teaching at ________at this time, below is an email where you can reach me.
You have all done a courageous thing, and I am so impressed that you have done it. Between raising children, owning and renting homes, working 11-7, maintaining family obligations, getting ready to have a baby, or saying goodbye to your parents and loved ones, you have all undertaken a huge task and should be very proud of yourselves.
Congratulations, good luck, and please keep in touch as you enter the world of nursing. I look forward to hearing about your successes and challenges, and will entertain any questions you have along the way.
Keith Carlson, RN, BS
Friday, May 12, 2006
From ICU to Fishnet Stockings
I had not seen her for nine days. The last time I came to this nursing home, she had just been transferred from the hospital to this facility for some reconditioning and rehabilitation. After four weeks in the hospital---one of which was in ICU---she needed some time to gain back some strength. Today, two days before Mother's Day, I find her in her room with three of her daughters. They have brought all of her jewelry for their mother to select from, and I see my patient---all 375 pounds of her---perched on the edge of her bed. She is smiling, bedecked in pointy brown leather shoes, fishnet stockings, a skirt, a low-cut blouse, several gaudy necklaces, earrings, and a hat on her head at a jaunty angle. She beams at me as her daughters argue over some jewelry.
"Girls, muchachas---I'm not dead yet! That's MY jewelry anyway!"
The women continue their good-natured dispute, one daughter pocketing a key-ring she'd been eyeing.
"I'm not getting involved in this family argument, " I say, taking my place near the window.
We chat, and when questioned, my patient tells me that there's a Friday afternoon concert at 2pm downstairs, and she wanted to look nice for the occasion. With most of the residents of this home 20-30 years her senior and confined to wheelchairs in the hallway, my patient looks like she's from another world. And indeed she is. An enormous Latina woman relegated to this facility of mostly white elders with various diseases of the aged, she is out of place, I must admit. There just don't seem to be any rehab facilities specifically for the younger set. Not much money in it, I guess.
As we talk some more, her daughter admonishes my patient for talking to me from under the visor of her hat with her eyes hidden from my view the whole time. She tips the hat back and smiles sheepishly.
I wish her a fun time at the concert, a lovely Mother's Day with family visiting her with homemade Puerto Rican food on Sunday, and I promise to stop by every week until she comes home. She thanks me, her daughters turn back to the jewelry, and I make my way back down the hall among the maze of dazed-looking residents parked along the walls in their wheelchairs. I picture my aging parents in such a place and cringe. The ubiquitous smell of urine and feces is a reminder of where I am.
Outside, the rain pours down, and I open my umbrella for the dash to the car. A few more home visits and then back to the office. Another day in the life.....
Thursday, May 11, 2006
GR, v. 2, n. 33
Tuesday, May 09, 2006
That said, this conference fed my soul like no other has in some time. Aside from the keynote speaker (the main attraction for my attending in the first place), this experience renewed my sense that there are countless healthcare professionals out there who are willing to put time and energy into personal growth, as well as the spiritual needs of their patients. While the majority of the attendees were nurses, there was adequate representation by pastoral counselors and social workers, as well as a smattering of occupational and physical therapists, a recreation therapist for seniors, and a small cadre of open-minded and interesting physicians. The main speaker explored some very cogent ideas related to spirituality, care of the psyche of the patient and caregiver, as well as the more ancient underpinnings of the roots of some modern medical and psychiatric practices.
To wit, I learned that the etymological roots of the word psychotherapy lead us to understand that "psycho" means "psyche" which in the original Greek meant "soul", and "therapy" comes from the ancient Greek word "theros" meaning "nurse". Hence psychotherapy actually means literally "to nurse the soul".
I also learned that Heraclitus said that "you can never discover the limits of the soul, no matter how many roads you take, so deep is its mystery." This one is worthy of further exploration, perhaps in a future post. This led to a discussion centered around the notion that while "spirit" speaks of things of a higher nature, as in spirituality, the intellect, and connection to a higher source beyond the earth, "soul" traditionally refers more to things closer to earth---or actually in the depths. While spirit gives us our connection to the greater and larger, soul gives us our connection to the internal, the underworld, the underbelly of the self. They don't say "dark night of the soul" for nothing......
Other ideas which were floated:
How does it feel when we walk into a clinic or hospital? What are the textures and colors like? Is it inviting? Are the artistic depictions of humans normal and colorful and full of life, or are the exam rooms filled with pictures of diseased organs and flayed bodies showing everything that could be wrong with one's internal organs? Do we have flowers in the exam room or little plastic models of disembodied kidneys? Is the waiting room like a living room or a bus station? How do we make our healthcare facilities more healthy and inviting, more nurturing of the soul and spirit, more restful?
Finally, one of the best quotes of the day came from a participant who shared a story of a patient who approached the dying process with great humor, aplomb, and dignity. He had said one day, "I've never seen a hearse pulling a U-Haul." That one really gave me pause and perhaps will be fodder for a future post as well. Gives new meaning to the phrase, "you can't take it with you."
All in all, a nurturing day of reinvigoration and release. Gratitude all around.
Monday, May 08, 2006
Cities, Violence, and Loss
There's a scene in My Dinner With Andre---one of my favorite films of all time---in which the main character describes for his dinner companion his vision of New York City. He describes a city which is in fact an ersatz prison in which the citizens were originally the inmates but eventually became their own guards, holding the keys to their own freedom but blindly perpetuating their own misery and isolation. Does the fate of such troubled cities indeed rest in its citizens' hands, and does the power to alter the fate of the inhabitants actually reside in the streets and homes and businesses which make up that urban conglomeration of people and lives?
This little city where I ply my trade is riddled with corruption, violence, cronyism and poor management on most every level. Drugs and gangs seem to rule the streets, the police and city hall fighting a losing battle against the perpetual tide. The saddest part of this brutal equation are the innocent lives which are shattered, literally caught in the crossfire, taken out in the heat of the moment, murdered for a pittance.
Where is the power to change? Where does it reside? In whom does the responsibility rest? Can cities such as ours turn themselves around, and if so, what will it take?
We grieve for the family of the murdered elderly couple, bereft of their parents and grandparents, who lived quiet and humble lives in a city they called home. May their souls rest in peace, and may their grieving family members eventually find healing and solace.
Sunday, May 07, 2006
Winding Up, Winding Down
This week marks the end of my current teaching career. I must say, no matter how much I love my students---and I do---it will be a sweet relief to no longer have exams, lectures, overheads, power-points, and other detritus to deal with all year. I truly love the act of teaching---the moments of laughter, of watching a student "get" something crucial, the crystallizing ideas coalescing in understanding and synthesis---it is very gratifying. But on top of a full-time job that demands such energy and commitment, teaching has been a psychic burden which I am ready to shed.
Beyond the mechanics of teaching, and the preparation and responsibility involved, I have always found nursing school to be somewhat deadening. The rote memorization, the need to teach towards the licensing exam---it all makes the process less alive for me. Grading students on their performance on multiple-choice tests is a frustrating but necessary evil which sometimes precludes the desire to spend time delving deeper into issues which cannot be addressed on such standardized exams.
In my teaching, I try to impart my excitement, my fascination, my sense of justice and socioeconomic equality, my commitment. I try to use stories, scenarios, and anecdotes to illustrate the reality of patient-provider interactions and the mystery and subtlety of such relationships. Sadly, the reams of information needing to be reviewed and lectured upon often precludes such non-linear teaching, keeping us information-oriented, away from the realm of feelings and relationships. This is a hole in nursing education, and area which I think is often overlooked in the interest of the "harder" scientific aspects of nursing.
I will honestly miss teaching, but I'll be sure to find opportunities for teaching which do not necessitate my standing in a classroom and talking until my throat is hoarse. In my mind, there are many changes needed in nursing education which I will not address in this forum, but I recognize that there are areas sorely lacking and in need of attention, especially on the comunity college level. Some day, perhaps, as a retired nurse, I'll return to academia and give it my all, acting as a change agent to reinvigorate the education of nurses. For now, I will gracefully bow out of that world, and leave the teaching to others more comfortable with the process than me.
Saturday, May 06, 2006
Recovering and Recharging
This skill of recovery and recharge is a learned skill---it is not necessarily innate. At times it seems easier to remain on that track, following the ego's drive towards doing rather than being. My desire is to accomplish what needs to be done over the weekend, but rest my mind and heart from the week's ups and downs.
Balance is called for---the balance of doing and being, of mindful action and thoughtful repose. Recovery and recharge should not be just another task to accomplish and cross off the to-do list---it is a state of mind, and one which, unfortunately, I must consciously steer myself toward.
Wednesday, May 03, 2006
Laying on her bed in a slowly emptying apartment---she's selling everything she owns in preparation for the journey---she looks more and more wasted and wan each time I visit. Although the visiting nurses come twice a day, I'm shocked that they haven't noticed the reddened areas on the iliac crests, a sure sign that skin breakdown and bed-sores are on the way without intervention. I also notice that the inside bony prominences of the knees are very red--she is laying on her side with knees together almost all day and night. I instruct her to put a pillow or folded towel between her knees at all times when in bed. I'm disappointed the VNA didn't catch these subtle but crucial changes.
She shares that she hasn't taken her antiretrovirals (the meds used to control HIV) for a week because she vomits whatever she puts in her stomach. I plan to order meds for these symptoms within the hour after a quick call to my NP colleague. We speak of other symptoms, I take notes, and the HIV case manager who I brought along probes more deeply for answers which I think may be more forthcoming in the presence of this other compassionate professional that she has known since first arriving here.
While she doesn't speak of depression per se, this is a spiritual crisis of huge proportions, and it is clear that faith and the power of the mind are hard at work. This individual may have only completed the fourth grade, but there is a depth of soul and spiritual wisdom that far outweighs any intellectual capacity which might be lacking.
We discuss more concrete issues and plans, medications, symptoms, egg-crate mattresses, bed-sores, diabetes, and the need for Ensure and vitamins. We make some decisions, look forward to some changes which may alleviate some discomfort, and prepare for a day in the near future when she will leave this lonely apartment behind and return to her hometown. The sirens, the jackhammers of the construction crews, the smell of exhaust through the open windows, the long winters, they will all be a thing of the past, a figment of memory. She will stay with her sister, her brother and father down the street, cousins and other extended family nearby. Perhaps these five years in New England will then seem like a dream, an extended journey which perhaps occurred on some other plane of existence. Perhaps when she hears those familiar tropical sounds---the birds, frogs, and insects of her beloved island---and smells the soil, air, ocean breeze and rich home cooking---it will be like returning to the womb, to the culture and land which cradled her from birth to adulthood.
I regret not setting more services in place sooner, but each week I add yet something more in order to assuage suffering or alleviate symptoms. Since she is too weak to go to the doctor lately, it feels like I'm running the show, bringing reports to the primary physician after each of my home visits, making recommendations, and getting a green light on most every suggestion I make. This is where my role is crucial. This is also where the stakes are higher and my errors of judgement or lack of action could have dire consequences.
My goal is to keep her healthy enough to make the trip, leave this odd New England world behind, and melt back into the comfort and familiarity of home and family. Gods, goddesses and angels of comfort and healing whose very existence I often question, bless these ensuing weeks and allow safe passage for this dear soul, and guide me well in my actions. If home is where the heart is, then bring this child where her heart longs to be.
Tuesday, May 02, 2006
Grand Rounds Again
Monday, May 01, 2006
What Price Efficiency?
In the course of my day, I checked email; answered calls; visited a dying patient at home and counseled his wife on the need to now decrease fluids and nutrition in the interest of comfort (more on that perhaps tomorrow); visited a patient in a nursing home; picked up flowers and coffee and chocolate for Mary on her first day of her new job, then picked up seven orders of falafel for Mary and coworkers at a downtown restaurant. After lunch, I sat in on a visit with a patient and a doc who was unfamiliar with her, sent some faxes, made calls, met with my boss, wrote my notes, and then tied up the loose ends of the workday in preparation for teaching from 6:30-9:30. Between 5 and 6pm, I sat at my desk and finished writing an exam for tomorrow's class, emailed it to the college for xeroxing and had a snack before driving up to the college to teach. The came a few hours of lecturing on HIV which I actually really enjoyed. Phew.
On the way home I called my mother from my cell phone, then debriefed with Mary about our days while giving Sparkey his meds, packing my bag for the gym tomorrow morning, loading Mary's car with some things for her new office, taking a bath with Mary, then giving Sparkey his IV fluids. Phew again.
Now I am finally in bed and letting my thoughts flow as I wonder indeed what price I pay for trying to do so much.
Living a full life? Agreed.
Enough leisure time? Almost never.
Chronic pain and fatigue? Often.
Does something have to change in this picture? The answer seems easy enough.


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Bacteriological findings in children with haematological disorders
Abstract number: 902_p1432
Kowalska-Krochmal B.
Infections in neutropenic children in the haematology ward is a significant therapeutical problem. The aim of this study was the analysis of frequency of isolation and antibiotic susceptibility of bacterial strains from children hospitalised in the Haematology Clinic in Wroclaw in the period 19992000 vs. 20012002.
Various clinical samples (blood, urine, faeces, material from respiratory tract and other materials) were examined. Isolated bacterial strains were identified by bioMerieux tests. Antibiotic susceptibility was examined by ATB tests (bioMerieux) and the disc diffusion method (NCCLS).
During the periods compared the total number of isolated strains was 785 and 1923 (blood 194 and 283). Significant changes in percentage of Gram-negative and Gram-positive isolates from blood (from 30.4% to 55.8% and from 69.6% to 44.0%, respectively) were noticed. Among the 1923 bacterial strains isolated from all the materials in 20012002, 53% were Gram-positive and 47% Gram-negative. In the group of Gram-positive strains (n = 1017), coagulase-negative staphylococci (CNS), streptococci orale and enterococci were dominant (32%, 31% and 23% respectively); in the group of Gram-negative strains (n = 906) it was mainly Escherichia coli, nonfermentative rods (P. aeruginosa excluded), Klebsiella and Enterobacter (31%, 12%, 11% and 10%). The results of antibiotic susceptibility were as follows:
in the group of Gram-positive bacteria glycopeptide-resistant strains were not found,
there were 75% MRS (methicillin resistant Staphylococcus) strains among CNS and 24% among S. aureus,
Increase in antibiotic resistance of Gram-negative rods especially among E. coli (to amoxicillin/clavulanic acid), P. aeruginosa (to netilmicin, ceftazidime) and other nonfermentative rods (to ceftazidime, piperacillin) was observed,
Gram-negative rods were highly susceptible to imipenem (96%), meropenem (94%), piperacillin/tazobactam (84%), ciprofloxacin (80%) and ceftazidime (79%); among carbapenem-resistant strains there were mainly nonfermentative rods (P. aeruginosa inclusive).
1. Rising trends were observed in the number of Gram-negative isolates from blood and in antibiotic resistance of all Gram-negative rods. 2. The empiric therapy with piperacillin/tazobactam plus amikacin in children with cancer treated in the Haematology Clinic seems to be the optimal option, but the monitoring of antibiotic susceptibility of bacterial strains is still required."
Session Details
|Session name:
|XXIst ISTH Congress
|Oxford, UK
|Presentation type:
|Back to top

subset: commoncrawl


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We look forward to seeing everyone on 9/29/13. If you have any questions please contact us at: firstname.lastname@example.com
- The "Ride for Justice" leaves St. Paul Catholic High School in Bristol, CT and follows a scenic route along country back roads into prime Connecticut Fall Foliage areas! We will travel through Bristol, Burlington, Harwinton, Terryville, Wolcott and Plantsville, arriving at Bozzuto's Food Distribution Center in Cheshire in time for an awesome Outback Steak House family style BBQ.
- Registration at St. Paul Catholic High School from 9:00 to 11:00 am
- Ride leaves at 11:30 am
- Live Entertainment starts at 9:00 am at St Paul High School with Face4Radio and at 12:30 pm at Bozzuto's with The Happening! Come early and bring a friend!


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You Are Here: Home » Disorders A - Z » Landau-Kleffner Syndrome »
Landau-Kleffner syndrome (LKS) is a rare, childhood neurological disorder characterized by the sudden or gradual development of aphasia (the inability to understand or express language) and an abnormal electro-encephalogram (EEG). LKS affects the parts of the brain that control comprehension and speech. The disorder usually occurs in children between the ages of 5 and 7 years. Typically, children with LKS develop normally but then lose their language skills for no apparent reason. While many of the affected individuals have seizures, some do not. The disorder is difficult to diagnose and may be misdiagnosed as autism, pervasive developmental disorder, hearing impairment, learning disability, auditory/verbal processing disorder, attention deficit disorder, childhood schizophrenia, or emotional/behavioral problems.
Treatment for LKS usually consists of medications, such as anticonvulsants and corticosteroids, and speech therapy, which should be started early. A controversial treatment option involves a surgical technique called multiple subpial transection in which the pathways of abnormal electrical brain activity are severed
The prognosis for children with LKS varies. Some affected children may have a permanent severe language disorder, while others may regain much of their language abilities (although it may take months or years). In some cases, remission and relapse may occur. The prognosis is improved when the onset of the disorder is after age 6 and when speech therapy is started early. Seizures generally disappear by adulthood.
The NINDS supports broad and varied programs of research on epilepsy and developmental disorders. This research is aimed at discovering new ways to prevent, diagnose, and treat epilepsy and developmental disorders and, ultimately, to find cures for them.
Epilepsy Foundation
8301 Professional Place East, Suite 200
Landover, MD 20785-7223
Tel: 301-459-3700; 800-EFA-1000 (332-1000)
Fax: 301-577-2684
National Organization for Rare Disorders (NORD)
55 Kenosia Avenue
Danbury, CT 06810
Tel: 203-744-0100; Voice Mail: 800-999-NORD (6673)
Fax: 203-798-2291
American Speech-Language-Hearing Association
2200 Research Boulevard
Rockville, MD 20850
Tel: 800-638-8255
Fax: 301-571-0457
Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient's medical history.
All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.
Last Modified June 30, 2015


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October 1997
This is really two albums in one: the title track and four succeeding selections comprise the 1963 LP of the same name, while tracks six through 13 come from Stitt's Now, a quartet date recorded three months earlier, which also uses pianist Hank Jones. All very pleasant goods with Stitt mostly on tenor. The title track, an uptempo blues, features chase choruses that go from 12 to two-bar exchanges. At nearly 73 minutes this is a terrific value, too!
Originally published in October 1997
BUY THIS ALBUM from Amazon.com
STREAM THIS CD from Rhapsody.com


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IEEE Viz Days 2 and 3
By Linda Fellingham on Oct 31, 2007
Day 2 I went to a workshop on Knowledge-Assisted Visualization. So what the heck does that mean? Mostly it meant using additional a priori information to add to the visualization (which seems kind of obvious) but there was one interesting paper about using statistics of the data to remove the expected (as in the statistical sense) information so the visualization only contains the interesting information. The results looked pretty good. It does seem to me that what is really of interest is visualization-assisted knowledge, but that is a different topic.
Day 3 started off with a keynote address by Rick Stevens of Argonne National Labs on "Visualization Challenges at the Intersection of PetaScale Computing and Biological Sciences". It was an amazing - to me, eye-opening - talk. I've been only peripherally observing the amazing advances in exploring genomes. But I had no idea the complexity of understanding the masses of data that have been uncovered. It is interesting that so much computer power has been applied to getting this information, but not so much to helping to understand it. Stevens showed a great animation that Harvard put together for their biology students ("The Inner Life of the Cell"} that was truly inspiring. I googled it and it can be found at http://www.studiodaily.com/main/searchlist/6850.html.
In the afternoon I went to another "Meet the Scientists" panel. The theme was too much data, inadequate visualization tools, help, help, help. It is really clear that more needs to be invested in visualization infrastructure to keep up with the massive investments in computing that is creating all this data that needs to be analyzed. Scientists want to be able to do interactive visualization to understand and analyze the terabytes (soon petabytes) of data they are continually acquiring. There seems to be a slight mis-match between the many in the vis community thinking that the visualization is the end result, and the scientific community needing visualization to be part of the analysis process.


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ATHENS, Ohio — Employee-trimming programs that Ohio University launched last spring left some unanticipated holes in the staff.
The Athens Messenger reported that 295 faculty and staff have voluntarily left the university since March 2011 through early retirement and voluntary separation plans launched at that time.
A memo to university trustees from Vice President for Finance and Administration Stephen Golding said that percentages of participation for eligible faculty and staff were higher than projections for both groups. He said that, because of the high volume of departures, the university has been working to fill critical positions left vacant.


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At the retailer breakfast meeting at New York Comic Con, attending retailers received a number of premium incentive items that made their visit well worthwhile. And naturally they've turned up on eBay.
But one of them, Captain America #1 from the Marvel relaunch was still a month away from publication.
They were on sale at the show from $100-$200 and are getting around $50–$90 on eBay right now.
The question is… can you wait?
My answer?


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Search Results
We're sorry, no products were found for your search: bar unit with bottle and glass storage and upper display shelf
-this isif is to keep the search suggestions consistent- get some suggested content did you mean: bar unit with bottle and glass storage and ?
Search tips:
- Double-check your spelling or try varying the spelling
- Limit your search to one or two words
- Be less specific. Sometimes a more general search term will lead you to the right product


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NEW YORK (CBSNewYork) — For victims of Superstorm Sandy who have continued to struggle in the 14 months since, there is a place they can get toys for their kids for a price that's right.
As WCBS 880's Peter Haskell reported Tuesday, the store was set to be open until 7 p.m. Christmas Eve at 1547 Arthur Kill Rd. on Staten Island.
Many families who were affected by Sandy still feel like they have been forgotten. For that reason, the group Where to Turn has opened the toy store where everything is free.
"It gives them a good feeling, that at least some people think they are not forgotten, and still working out on their behalf," said executive director Dennis McKeon.
There is something for almost everyone.
"We have toys for pretty much all ages, from newborn up to early teens," McKeon said.
The toy store has recently received a delivery of 700 Hess trucks. Families need to bring their Federal Emergency Management Agency identification numbers to use the store.
The group said earlier this month that its goal was to give out 15,000 toys to Sandy victims.
You may also be interested in these stories:


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I have seen plenty of cellphone cases but these just take the cake. These bejeweled works of art for your cellphone is from a site called LuxAddiction. What ...On March 31, 2010 / By Chip Chick Staff
iPhone and iPod Touch cases are basically what all the sites talk about about when it comes to accessories – we are no exception. But lets talk about ...On January 19, 2010 / By Ali Heriyanto
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An Arizona official has refused to accept an application from prospective operators of a medical marijuana dispensary, setting the stage for a possible legal challenge.Read More »
Well, we did miss out on Prince William's wedding
Brewer will be among the Arizona contingent jetting off to Paris next month to attend the city's famed air show with Arizona Commerce Authority Director Don Cardon.Read More »
Arizona-Mexico Commission holding first session since SB1070
After two cancelled meetings and more than a year of controversy, the Arizona-Mexico Commission will hold its first plenary session since the advent of SB1070.Read More »
Immigrants worry about upcoming ID card law
Arizona will no longer recognize photo-ID cards issued by foreign consulates beginning July 20. The state legislature passed the bill as part of a package of illegal-immigration measures.Read More »
Memorial to 9/11 preaches vengeance and tolerance
Matthew Salenger etched 54 phrases in a circular piece of steel, building Arizona's Sept. 11 memorial one story at a time. He wanted everyone's story to be told. Salenger thought that all of those thoughts could coexist peacefully on a public memorial. He was wrong.Read More »
Pearce now faces possible recall vote
State Sen. Russell Pearce was riding high last year, notching wins that include enactment of a second Arizona law to crack down on illegal immigration and then his selection by fellow Republican senators as the chamber's new president.
This year, things haven't gone so well for the tough-talking former lawman.
We're in the money… comparatively speaking
Arizona's recovery is holding steady. JLBC reported that, for the ninth consecutive month, April posted year-over-year growth in revenue collections.Read More »
Escaping his 'comfort zone:' How an experience in Rio and a Vince Lombardi quote led Justin Pierce to a House seat
Justin Pierce remembers when the calls started coming in.
Former House Speaker Kirk Adams had officially announced his resignation and the precinct committeemen for Legislative District 19 were beginning their search for a replacement. Pierce, a labor attorney, son of Arizona Corporation commissioner and former state lawmaker Gary Pierce, a grassroots activist and generally affable guy, was on their list of people they'd like to see in the House seat.
A battle of wills: Legislature tried to stop the Voter Protection Act before it started
Republican legislators have spent the past 12 years railing against the Voter Protection Act, but the reviled ballot measure that tied lawmakers' hands was a largely self-inflicted and ironically unnecessary wound.Read More »
Fit to be tied: Republican lawmakers say Prop. 105 is too restrictive
The chorus of lawmakers calling for an overhaul of the Voter Protection Act quieted to a low murmur in 2011, but supporters say the dormant issue will be back on the Legislature's agenda next year.
Several Republican legislators said they will revive their plans to change Proposition 105, the 1998 ballot measure that strictly limits the Legislature's ability to tamper with voter-approved measures.


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Guanacaste is a Costa Rican province located in the northwest, bordering Nicaragua, and contains some of the most popular destinations in the country; including the surf town of Tamarindo, the stunning Conchal Beach, and Liberia, the capital of Guanacaste.
A large portion of Guanacaste stretches across the pacific coast, causing the area to be a tourist hot-spot, but is also an increasingly popular place for permanent residency among expatriates. The region boasts plenty of ocean view properties, nearly unparalleled in beauty. Conchal beach, located in northern Guanacaste near the towns Brasilito and Flamingo, is striking beyond imaginable!
Just a few drops of rain fall from December to April, which is dry season in Guanacaste, is considered summer in this part of Costa Rica. With long, hot, sunny days during the dry season, the region comes to life. Visitors and part time residents to flock to the area's magnificent beaches and never ending sun.
The period from May to November is considered rainy season, or winter. During rainy season, the sun still rises at 5:30 in the morning and may shine through the entire day. During most days, however, it will rain for an hour in the afternoon and sometimes another hour at night. Towards the end of rainy season, in September and October, a few stretches of days will experience torrential downpours. These months are the quietest time of the year for tourism in Guanacaste. But for those who are considering relocating to this region, a couple days of rain is probably significantly more appealing than whatever winter produces back home!
Not all of the province sits on the coast, so tourism isn't the only thing keeps things moving in the area. The root of Guanacaste's economy is centered on beef cattle ranching. However, because of a lessened international demand for beef, some of the extended pastures of grasses for cattle ranching are being converted to tree plantations, or are simply transitioning back to dry forests naturally.
In the mid 2000s, land in the province was rapidly being purchased by investors. However, since the housing boom, up until recently, homes and properties were basically idling, with very little growth occurring. But now, interest in the area is mounting, especially in the ocean side areas. People are once again looking to purchase property and homes in the area, though, much of the activity involves soon to be expatriates, ready to life the hammock-laden or beach chair life awaiting Costa Rica.
Overall, Guanacaste is currently a thriving portion of Costa Rica, and is only growing. A brand new airport and hospital just began operation in Liberia, and more infrastructure and amenities are consistently moving into the area. For anyone looking to relocate or travel to Costa Rica, Guanacaste certainly offers some of the premier spots in Costa Rica!


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The Motorola ATRIX HD for AT&T – the successor the Atrix 2 which previously leaked out as the Motorola Dinara – has been made official on the Motorola website. In keeping with the new design standard at Motorola, the ATRIX HD sports a Kevlar coated back and runs Ice Cream Sandwich with minimal customization and the standard Android 4.0 on-screen navigation buttons.
Take a look at the official specs:
- 1.5 GHz dual-core processor
- 4.5″ HD ColorBoost TFT LCD display
- 8 MP rear camera with 1080p recording and 1.3 MP front facing camera
- 8GB onboard storage expandable via microSD
- 4G LTE connectivity
- 1780 mAh battery
- Android 4.0 Ice Cream Sandwich
The details about the processor aren't specific, but it wouldn't be surprising to see it running on the Qualcomm Snapdragon S4 due to its 4G LTE radio. As for further concrete details and the release date, we'll let you know when further info gets out. Stay tuned!


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ARTIST/PUBLISHER Jason Dube has been self-publishing under his comic book company Scattered Comics for the past 14 years. He has published titles such as Scattered, Panda Days, Caffeine Poisoned, and Waiting for Something to Happen. He has recently began putting out monthly webcomics, and branched out to releasing his titles to download on I-tunes. Jason also working as a fulltime freelance comicbook artist has worked as artist, colorist, typesetter and layout artist for several independent companies. (Companies include NEKO PRESS, BLUE WATER PRODUCTIONS, COMICBOOK DIVAS).
Dube has recently opened an art studio (Scattered Comics Studios) where several artists work under me to help with the expanding workload that I have been bringing in from other clients.


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International Dewey Users Meeting
Este evento já aconteceu.
The following presentations were made at the International Dewey Users Meeting, held on 16 August 2011, at the 2011 IFLA conference. All links will open a PowerPoint (.ppt) presentation.
- DDC 23: It's Here! (1,433 KB) presented by Joan Mitchell, Editor in Chief, DDC, OCLC
- EDUG: European DDC Users Group (403 KB) presented by Patrice Landry, Swiss National Library
- Expansions and Revisions in 297 for Islam: DDC 23 and Proposed Updates (357 KB) presented by Julianne Beall, Assistant Editor, DDC, Library of Congress
- Updates to MARC 21 Formats (286 KB) presented by Joan Mitchell, Editor in Chief, DDC, OCLC
- WebDewey 2.0 Enhancements (1,671 KB) presented by Libbie Crawford, Product Manager, DDC, OCLC and Michael Panzer, Assistant Editor, DDC, OCLC
- What Else Can You Do with Dewey? (7,281 KB) presented by Diane Vizine-Goetz, Senior Research Scientist, OCLC
Data de início
16 Agosto 2011
Data final
16 Agosto 2011


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Mehta, Shruti Ha; Lucas, Gregory Ma,b; Mirel, Lisa Ba; Torbenson, Michaelb; Higgins, Yvonneb; Moore, Richard Da,b; Thomas, David La,b; Sulkowski, Mark Sa
From the aDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, USA
bDepartment of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Received 11 May, 2006
Revised 3 August, 2006
Accepted 5 September, 2006
Correspondence to Mark S. Sulkowski, MD, Department of Medicine, 1830 E Monument St, Suite 455, Baltimore, MD 21287, USA. E-mail: firstname.lastname@example.com
Objective: To evaluate predictors and trends of referral for hepatitis C virus (HCV) care, clinic attendance and treatment in an urban HIV clinic.
Design and methods: A retrospective cohort analysis in which 845 of 1318 co-infected adults who attended the Johns Hopkins HIV clinic between 1998 and 2003 after an on-site viral hepatitis clinic was opened, attended regularly (≥ 1 visit/year for ≥ 2 years). Logistic regression was used to examine predictors of referral.
Results: A total of 277 (33%) of 845 were referred for HCV care. Independent predictors of referral included percentage elevated alanine aminotransferase levels [adjusted odds ratio (AOR) for 10% increase,1.16; 95% confidence interval (CI), 1.10–1.22] and CD4 cell count > 350 cells/μl (AOR, 3.20; 95% CI, 2.10–4.90), while injection drug use was a barrier to referral (AOR, 0.26; 95% CI, 0.11–0.64). Overall referral rate increased from < 1% in 1998 to 28% in 2003; however, even in 2003, 65% of those with CD4 cell count > 200 cells/μl were not referred. One hundred and eighty-five (67%) of 277 referred kept their appointment, of whom 32% failed to complete a pre-treatment evaluation. Of the remaining 125, only 69 (55%) were medically eligible for treatment, and 29 (42%) underwent HCV treatment. Ninety percent of 29 were infected with genotype 1 and 70% were African American; six (21%) achieved sustained virologic response (SVR). Only 0.7% of the full cohort achieved SVR.
Conclusions: Although the potential for SVR and the recent marked increase in access to HCV care are encouraging, overall effectiveness of anti-HCV treatment in this urban, chiefly African American, HCV genotype 1 HIV clinic is extremely low. New therapies and treatment strategies are an urgent medical need.
Because of shared routes of transmission, 15–30% of HIV-infected persons are co-infected with hepatitis C virus (HCV) [1]. In comparison with those infected with HCV alone, HIV/HCV co-infected patients progress more often and more rapidly to significant liver disease or cirrhosis [2,3]. With widespread use of antiretroviral therapy for HIV infection, co-infection with HCV has become a growing cause of morbidity and mortality among HIV-infected patients and in fact, in one center, it was estimated that 50% of deaths among HIV-infected patients were attributable to liver disease [4,5].
These data support prompt treatment of HCV among co-infected patients. Current treatment guidelines recommend combination therapy with pegylated interferon (pegIFN) plus ribavirin (RBV) for the treatment of HCV among co-infected persons [6,7]. Data from clinical trials suggest that HIV/HCV co-infected patients treated with this regimen have a sustained virologic response (SVR) rate ranging from 15% (genotype 1 or 4) to 70% (genotype 2 or 3) [8,9]. However, the uptake of HCV treatment among HIV/HCV co-infected patients has remained low among most populations. A number of studies have suggested that these low rates of treatment stem from high rates of treatment ineligibility due to medical and psychiatric contraindications, non-adherence to medical visits and concomitant alcohol and/or drug use [10–13]. Low referral rates of co-infected patients for hepatitis C care may further contribute to low treatment rates [14–17].
The Johns Hopkins University (JHU) HIV clinic is composed of over 3000 HIV-infected persons of whom approximately 50% are HCV-co-infected [18]. An on-site viral hepatitis clinic was established in 1998. The objective of this study was to examine trends and characteristics of HIV/HCV co-infected persons who were referred for HCV care after the establishment of this clinic. Among those referred, we also examined characteristics associated with clinic attendance and treatment initiation.
The population for this study derives from HIV/HCV co-infected members of the JHU HIV clinic cohort in Baltimore, Maryland [19]. Individuals were eligible for this analysis if they were seen in the JHU HIV clinic after 30 June 1998 when the Viral Hepatitis Clinic was opened and had their first visit to the HIV clinic by 31 December 2001, thus allowing for sufficient follow-up (n = 1318). The analysis was truncated in December 2003 because a clinical trial began in 2004 and recruited over 165 co-infected patients in 2004 from the HIV clinic. As many individuals received biopsies and treatment through this clinical trial, the estimates of referral for 2004 were likely to be lower. To be further eligible for analysis, it was required that individuals be in regular care for their HIV infection, defined as having at least one visit per year for at least 2 consecutive years. Of the 1318 HIV/HCV co-infected patients who were seen during the eligible period, 157 (12%) died within 2 years of their first visit after 1998 and 316 (24%) had insufficient follow-up (e.g. only one visit), leaving 845 who were included in the HCV referral and treatment analysis. With regard to sociodemographic characteristics, these 845 were not significantly different from other co-infected individuals in the clinic population who were not eligible for this study (n = 473, data not shown).
The HCV clinic is located physically within the JHU HIV clinic and care is delivered by five specialists (four physicians and one nurse practitioner). The clinic provides comprehensive evaluation and treatment of HCV infection on a referral basis that routinely includes an assessment of HCV RNA viral load and genotype. Those who are determined to be eligible for treatment are routinely recommended to undergo liver biopsy. Treatment eligibility is determined on a case-by-case basis taking into account medical and psychiatric co-morbidities as well as baseline laboratory values. Importantly, neither former nor active injection drug and/or alcohol use excludes an individual from treatment. Standard clinical practice is to offer treatment to all individuals regardless of stage of fibrosis on biopsy; however, emphasis is on treating individuals with significant liver disease disease (≥ stage 2 fibrosis). HCV treatment with interferon (IFN; standard or pegylated) plus RBV is available to all treatment-eligible patients through commercial insurance or state and federal government assistance programs (e.g., Medicaid and the AIDS Drugs Assistance Program).
For all HIV/HCV co-infected persons in the study sample, information on prescribed medications and laboratory parameters was obtained from the JHU clinical and laboratory database. As previously described, data on patient demographics, social practices, clinical and laboratory parameters and prescribed antiretroviral and other medications are collected and abstracted from patient charts by trained personnel and transferred electronically from the JHU laboratory database at enrollment and subsequent 6-month intervals [19]. Validity checks are performed periodically on a 5% sample of abstracted fields in the database and to date errors have only been found in 0.2% of variable fields. Longitudinal data on drug and alcohol use was only available on a subset of individuals who underwent an additional audio computer-assisted self interview (ACASI) that collected detailed information about these behaviors at 6-month intervals (n = 419 for alcohol data and 203 for drug-related data). The study was approved by the Johns Hopkins Medicine Intitutional Review Board and written informed consent was obtained from all participants.
First, characteristics of persons who were referred for HCV care were compared with those not referred using chi-squared tests for categorical variables and Mann–Whitney tests for continuous variables. Multiple logistic regression was used to determine independent predictors of referral. For individuals who were referred, covariates were taken from the last HIV clinic visit prior to referral and for those not referred the covariates were taken from the last HIV clinic visit prior to 2004. Using the same analytical techniques, we further compared characteristics of patients who completed and did not complete their appointment among those who were referred and of patients who initiated treatment compared with those who did not among those who had a complete evaluation. We also examined trends by calculating annual referral and completion rates considering in the denominator all individuals who were still in follow-up at the HIV clinic within the calendar year and had not been previously referred. Finally, association of calendar year of referral and characteristics that predicted referral were examined using an exact chi-squared test based on the Monte-Carlo method. Two-sided P values < 0.05 were deemed statistically significant. Data were analyzed using SAS software, version 9.1 (SAS Institute Inc., Cary, North Carolina, USA).
Among the 845 HIV/HCV co-infected individuals eligible for this analysis, the median age was 40 years, 63% were men and 85% were African American. Overall, 277 (33%) were referred for HCV clinical care (Fig. 1) and 185 (67%) of the 277 completed at least one appointment with the viral hepatitis clinic. Of the 185 who entered HCV care, 60 (32%) failed to complete the medical evaluation required to determine HCV treatment eligibility, leaving 125 fully evaluated patients. Of the 125, 56 (45%) were ineligible for treatment because of: no detectable HCV RNA (n = 9); end-stage liver disease (n = 19); advanced AIDS or less than 2-year life expectancy (n = 16); severe psychiatric disease (n = 6); and drug or alcohol use which precluded treatment adherence (n = 6). Of the 69 patients eligible for HCV treatment, 65 (94%) were infected with genotype 1 and 4 (6%) were infected with genotype 2/3. Liver biopsy results were available on 38, of whom 12 (31%) had no fibrosis (F0), 17 (44%) had mild-moderate fibrosis (F1–F2) and nine (24%) had cirrhosis (F5–F6). HCV treatment with standard or peg IFN plus RBV was initiated in 29 patients representing 23% of 125 fully-evaluated patients and 42% of eligible patients. Ninety percent of treated patients were infected with HCV genotype 1 and 70% were African American. Sustained virologic response (SVR) was achieved in six treated patients (21%) including 100% of those infected with genotype 2/3 (n = 3) and 12% of those infected with genotype 1 (n = 26). Reasons for not treating hepatitis C among treatment-eligible patients included mild liver disease (n = 30, 75%), and patient refusal or deferment (n = 10, 25%). Among all HIV/HCV co-infected patients receiving regular HIV care (n = 845), less than 1% were effectively treated for hepatitis C, defined as having achieved a treatment-related SVR (Fig. 2).
In the unadjusted analyses, when compared with those not referred for HCV care by their primary HIV care provider, referred patients were significantly less likely to be African American and less likely to have injected drugs in the preceding 6 months (P < 0.05; Table 1). At the time of referral, those who were referred were more likely to be in active psychiatric care, be on antiretroviral therapy (ART), tended to have lower HIV RNA levels, higher CD4 cell counts, higher alanine aminotransferase (ALT), aspartate aminotransferase (AST) and bilirubin levels and lower albumin levels (P < 0.05). There were no differences in referral by age, gender, alcohol use or drug treatment in the prior 6 months or prior AIDS diagnosis. In logistic regression analysis, independent predictors of referral to HCV care were being in active psychiatric care, undetectable HIV RNA, CD4 cell count > 200 cells/μl, being on ART, persistently elevated ALT levels, having an albumin < 3.5 mg/dl and having a bilirubin > 1.2 mg/dl. In the subsample that also had data on recent drug and alcohol use, undetectable HIV RNA, CD4 cell count > 200 cells/μl and elevated ALT remained independent predictors of referral. Further, in comparison with those who reported no drug use, those who reported recently using any drugs by injection were significantly less likely to be referred. However, enrollment in drug treatment programs (e.g., methadone maintenance) was not associated with referral status.
Among the 277 who were referred for care, compared with those who did not complete their first appointment (n = 92), people who completed their first appointment (n = 185) were significantly less likely to have used or injected drugs in the prior 6 months (63 versus 100%, P = 0.01) and were significantly more likely to be on ART (68 versus 47% taking ART at the time of referral, P < 0.01). Those who kept their appointment were also more likely to have persistently elevated ALT levels [median percentage ALT > 1.25 × ULN, 50 versus 30%, P = 0.06) and persistently elevated AST levels (median percentage AST > 1.25 × ULN, 57 versus 48%, P = 0.07). There were no differences with respect to other factors including CD4 cell count, HIV RNA level, albumin or bilirubin, all of which were associated with referral.
Among the 125 (of 185) patients who had a complete pre-treatment evaluation, we further examined the characteristics associated with treatment initiation (Table 2). In comparison with those who did not initiate treatment, those who did were less often African American (P = 0.05), less likely to have ever injected drugs (P = 0.03), more likely to have persistently elevated ALT and AST levels (P < 0.05), more likely to have CD4 cell counts > 200 cells/μl (P = 0.08) and more likely to have significant fibrosis on biopsy (P = 0.03) (Table 2).
The proportion of individuals referred increased over time from < 1% in 1998 to 28% in 2003 (Table 3). By contrast, the proportion of individuals who were referred and completed their appointment increased only from < 1% in 1998 to 13% in 2003, reflecting the observation that while the rate of referral increased over time, many of these referred patients failed to attend their scheduled hepatitis C appointment. Indeed, the 'no show' percentage increased steadily over time: 1999, 0%; 2000, 2%; 2001; 8%; 2002, 44%; and 2003, 53%. In comparison with those referred in earlier years, individuals referred in later years had lower CD4 cell counts, were less likely to be on antiretroviral therapy and more likely to have used or injected drugs in the prior 6-month interval (Table 3). Despite the observed increase in referral rate, even in 2003, 65% of patients with a CD4 cell count > 200 cells/μl and 30% of patients with undetectable HIV RNA were not referred for HCV care during the study time period.
In an urban setting with high rates of HCV genotype 1 co-infection, African American ethnicity and polysubstance abuse, we observed relatively low rates of referral for HCV care, HCV treatment initiation and limited effectiveness of antiviral treatment for hepatitis C despite the establishment of a dedicated, on-site clinic. Among those patients who initiated HCV treatment with standard or peg-IFN plus RBV, 21% achieved a SVR, which is similar to the SVR rate observed in pivotal clinical trials among patients with HIV/HCV genotype 1 co-infection [8,9,21]. However, while efficacy was comparable with that observed in controlled trials, real world effectiveness in this population was negligible as less than 1% of the full cohort of co-infected patients in HIV care achieved an SVR.
Low rates of overall treatment effectiveness have been observed in other co-infected populations as well. Among patients in HIV care in Rhode Island, only one of approximately 400 co-infected patients achieved SVR (overall treatment effectiveness, 0.2%) [22]. Similarly among 182 co-infected patients in a cohort study in San Francisco, only one person achieved SVR (overall treatment effectiveness, 0.5%) [23]. Interestingly, these rates are also similar to those reported in some HCV mono-infected populations. Among 1470 HCV-infected patients enrolled in the Kaiser Permanente Northern California Health System from 1999–2004, less than 17% underwent HCV treatment and the overall treatment effectiveness was less than 4% [21]. Similarly, in a study of 293 HCV mono-infected patients who were referred for treatment, only 28% were treated; of whom, 13% achieved SVR [24]. Comparable rates were observed in our population with 23% of those fully evaluated for treatment initiating treatment and 21% achieving SVR.
Multiple factors contribute to the exceedingly low impact of hepatitis C treatment in this and other settings. Despite financial access to on-site HCV care, nearly 67% of HIV/HCV co-infected patients were not referred by their primary HCV care provider. This low rate of referral is also consistent with what has been reported in other co-infected populations [14–17]. In general, HIV care providers in our setting tended to refer patients who had well-controlled HIV (e.g. undetectable HIV RNA, CD4 > 200 cells/μl and on HAART) and were not actively using drugs. Individuals with these characteristics were also more likely to initiate treatment. However, our data also indicate that many co-infected patients with well controlled HIV disease were not referred for HCV care. This finding suggests that additional programs to educate both health care providers and patients on HCV and its treatment should be developed and evaluated in this and similar settings.
Providers were also more likely to refer those with higher levels of liver inflammation as reflected by serum ALT and AST levels. Although it is important for those patients with more active liver disease to be referred, it is also well-established that ALT measurements are not necessarily predictive of underlying liver disease and patients with cirrhosis may have normal hepatic enzyme levels [25]. In fact, published guidelines for the management of co-infected patients indicate that serum ALT level should not substantially influence the decision to evaluate or treat hepatitis C [6]. Moreover, nearly 20% of patients evaluated in the HCV clinic had already progressed to end-stage disease by the time of their referral evaluation, rendering them ineligible for treatment. For these patients and others with significant liver disease, it is important that early referral afford them the opportunity to be evaluated for HCV treatment since current therapies are strictly contraindicated in the setting of end-stage liver disease and access to orthotropic liver transplantation is very limited.
It was encouraging that the rate of referral steadily increased each year, with a substantial rise in 2003 following the recommendation from the US National Institutes of Health Consensus Panel that HIV-infected patients, particularly those with stable HIV disease, should be considered for HCV treatment. However, our data indicate that referral for HCV care is necessary but not sufficient for effective hepatitis C treatment as nearly one-third of referred patients did not attend their HCV appointment. Indeed, whereas the absolute numbers of referrals and patients evaluated increased over time, actual attendance rate declined over time most notably in 2003, the same year that the referral rate had nearly tripled from the previous years. Whereas providers appeared to be following the revised guidelines by referring more patients with less stable HIV disease (e.g., CD4 cell counts < 350 cells/μl who were not on ART) and who were actively using drugs, these same patients were significantly less likely to attend their appointment.
Interestingly, psychiatric disease was not associated with lower rates of provider referral or patient compliance with HCV care appointments. In fact, in comparison with other co-infected patients, those actively seen in the psychiatry clinic were more likely to enter hepatitis C care. On the other hand, although psychiatric care appeared to facilitate entry into HCV care, active treatment of drug addiction did not, perhaps because whereas psychiatric care is available on-site at the JHU HIV clinic, drug treatment, and specifically methadone maintenance, is received in geographically and organizationally distinct off-site centers. Prior studies have shown that HCV can be successfully delivered in methadone maintenance treatment settings [26]. However, integrated care strategies that address all patient medical and psychosocial needs, while incorporating patient education, peer support, case-management along with on-site drug treatment are needed to truly improve show rates among persons actively using drugs. Some centers are beginning to launch such pilot programs; however few patients have been treated under this model thus far [27].
Patient eligibility for and willingness to take IFN plus RBV therapy were also important factors, as was the medical necessity of treatment. In our study, many patients who were fully evaluated for hepatitis C did not initiate HCV treatment either due to direct contraindication to the safe administration of these medications (e.g. decompensated liver disease, advanced AIDS, uncontrolled psychiatric disease) or indirect factors such as active substance use which precluded treatment adherence. These data regarding treatment eligibility are consistent with observations in other co-infected [10,14] and mono-infected populations [24], although definitions of eligibility tend to vary across studies. In addition, more than 75% of treatment-eligible patients in our clinic with minimal histologic disease did not initiate therapy, choosing to defer a potentially toxic, relatively ineffective therapy in the setting of other comorbidities (e.g. drug use and psychiatric disease). Conversely, 53% of those with significant fibrosis were treated. However, this and multiple other studies suggest that SVR rates are lower among persons with cirrhosis in comparison with those with minimal histologic disease, which lends support to the hypothesis that HIV-infected patients should be treated even in the setting of minimal histologic disease [28].
Overall, consistent with published guidelines, treatment decisions were based on case-by-case assessments of potential risk and benefits of HCV therapies, a reasonable strategy until more efficacious therapies become available. The current standard of care, peg-IFN-α plus RBV, has relatively low efficacy in persons infected with HCV genotype 1, particularly those with high levels of hepatitis C viremia, African American ethnicity and HIV co-infection. Indeed, among carefully selected patients enrolled in clinical trials, SVR has been observed in only 14–29% of such patients [8,29–31]. Thus, our SVR rate (21%) compares favorably with similar therapies in these other populations and reinforces that the efficacy of the currently available medications is only one factor that reduces overall treatment effectiveness. However, even with more efficacious therapies, much work is needed before the efficacy rates observed in clinical trials translate into effectiveness at the level of the co-infected patient population. Given that 67% of co-infected patients in the clinic population were not even referred for HCV care and less than 15% underwent such a systematic assessment of HCV disease risk and need for HCV treatment, efforts should focus first on improving referral and attendance rates. In this regard, given that the major barriers to being referred for HCV care appeared to be uncontrolled HIV and drug use, further integration of HCV care with HIV care and substance abuse treatment would likely improve referral and attendance rates.
We were limited in this analysis by not having HCV RNA data on the full sample of participants and it is likely that some of the 845 patients did not need to be referred for care based on the absence of detectable HCV RNA. However, data from a random sample of the same clinic observed that only 11% of HIV/HCV co-infected persons were HCV RNA negative (unpublished data). Further, given that HCV RNA testing is not part of routine HIV clinical care in this clinic, it is unlikely that this issue significantly impacted HCV clinic referral patterns. We were also limited by not having drug use data on the full sample of patients which prohibited multivariate analysis of predictors of appointment attendance and treatment initiation.
In conclusion, we observed limited effectiveness of HCV therapy in a population of HIV/HCV co-infected individuals engaged in regular health care with the ability to access HCV care in the absence of financial or geographical barriers. New paradigms for HCV care are urgently needed in these populations, ones that incorporate patient and provider education as well as case management to address competing needs including substance abuse, psychiatric illness and HIV. Our findings further underscore the well-documented low efficacy of current HCV therapeutics in persons co-infected with HIV and HCV genotype 1, particularly African Americans. Novel therapies, such as HCV polymerase and protease inhibitors are currently under investigation and our data highlight the urgent medical need of co-infected patients for access to such novel anti-HCV agents.
Financial support for this study came from DA-11602, DA-16065 and DA-3806 from the National Institute on Injection Drug Abuse, grant HS 07–809 from the Agency for Health Care Policy and Research and MO1-RR00052.
HIV; hepatitis C; referral; intravenous drug abuse; antiviral therapy
© 2006 Lippincott Williams & Wilkins, Inc.
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Discussion (19) ¬
Now I always thought she took a big gamble in doing this. It could have landed in someone else's bowl.
I think that the soup was meant for him alone.
Yeah, the cook told All Fur to make the king's soup on page 12.
True, unless the king has his own bowl, or this scene is after party (not likely thought).
Whenever I read this tale, I always imagined the Prince choking on the pieces of jewelry All Fur slips in his entrees. :D But, then again I guess if the ring is pure gold, it would be heavy and sink to the bottom!
So the neighboring king(it wasn't a prince) might just figure her out.
Lucky king, he got a prize in his soup!
Medieval version of getting a cheap toy in cereal – a free gold ring in every bowl on soup!
At least he didn't swallow it. D:
Ah, so those glow-in-the-dark plastic watches weren't just a cheap attempt for me to beg my mom to buy sugar-coated starch, it was actually part of a rich cultural tradition!
The more you know….!
I thought this scene didn't happen until all three dresses had been worn. Or is this one of the versions where she slips something into the soup three times?
@AdamYJ I believe it's one of the versions where she does just that, according to the tale I've read.
The version's I've read, she slipped something in each time.
why is he so CUTE and DELIGHTED with everything? goodness.
I think this was an accident dropping it in the soup. And it looks like the king is eating by himself…
THIS SOUP. THIS IS THE BEST SOUP. lol.
I LVOE the Prince!! Reminds me of Raj from Big Bang Theory. :D
"What's it say…DRINK…YOUR…OVALTINE"
What an awesome way to explain this-now I know evityrheng!


text: PA Synergy Softball - Friendly's Family Fun Night - October 20th Skook News 11:59 AM Events Edit Share on Facebook Share on Twitter Share on Google Plus About Skook News This is a short description in the author block about the author. You edit it by entering text in the "Biographical Info" field in the user admin panel. RELATED POSTS


text:
1-9 of 9 companies for Lebanon : "main"
Nohra General Motors S.A.R.L
Good Morning and have a nice day,Nohra General Motors S.A.R.L is a trading company in Lebanon taking care of Diesel Engine Spare Parts, we are working more than 30 years with diesel industry and now we grow up and we grow up in our parts.
Bou Gharios - BGB
Bou Gharios - BGB is a registered company which main activities are the manufacturing, trading and export of agricultural and food products as well as alcoholic and non-alcoholic drinks
Business Type: Manufacturer, Exporter
Category: Food & Beverage | Other Alcoholic Beverages
Choueiri Trading Est.
we are importers of inkjet refill kit and refurbished cartridges.suppliers are welcomed to send their offers via e-mail or mail post
Business Type: Importer, Agent, Wholesaler/Retailer
Category: Business Services | Marketing Consulting
Aslanian Trading
Aslanian Trading is specialized in providing different services and products in the olive oil industry. Selling, assembling and repairing different parts of the whole spectrum of an olive oil plant is our main specialization. We also sell olive oil, soap
Business Type: Service
Category: Business Services | Agriculture Products Processing
Al-Rida Computers is main computers shop in north lebanon
Business Type: Exporter, Importer, Distributor, Wholesaler/Retailer
Category: Computer Hardware & Software | Desktops & Servers
Rizk Trading CO.
We are a major tyre importer and distributor in the Middle east area. We mainly operate in the Syrian and Lebanese market. But we also have our clients in Iraq, Jordan and Africa.You are welcome to contact us for any Buying or selling inquiry.
Business Type: Exporter, Importer, Agent, Distributor, Wholesaler/Retailer
Category: Rubber & Plastics | Rubber Products
K.B. International
KBI is a fast growing, International Trading Company located in Lebanon. K.B.I is mainly engaged in the sale of various commodities, primarily through international trade. It has carved a respectable position in the global market.
Business Type: Manufacturer, Exporter, Importer, Others
Category: Chemicals | Other Organic Chemicals
KBI is a fast growing, International Trading Company located in Lebanon. K.B.I is mainly engaged in the sale of various commodities, primarily through international trade. we are committed to both honoring contract and customer service.
Business Type: Manufacturer, Exporter
Category: Chemicals | Other Organic Chemicals
Nassim Dagher Factories
Nassim Dagher Factories is specialized in the production of all kinds of detergents: powder, liquid and cream.Its main products are:- NONI powder detergent grated with soap and free of foam or enzyme- NONI cream cleaner - NONI liquid detergent
Business Type: Manufacturer
Category: Home & Garden | Household Chemicals


text:
Greetings Haverford!
First Collection is coming! Hurrah! But what is it, exactly? Perhaps the day valiant librarians riding book cart chariots storm the campus to retrieve the first wave of overdue books from this semester? Or, perhaps, the first day students take to the nature trail to collect fallen timber to keep warm fires going through the cold autumn nights?
(DISCLAIMER: no bonfires in the dorms.) In fact, it is something more subtle but no less exciting, and it is quite deeply rooted in Haverford's history.
First, some background on the Collection Committee, the organization that puts on the event. The Collection Committee began as a literal "collection," a campus-wide meeting which students were required to attend. It now serves to help bring new ideas and debate to campus, generally in the form of unique interactive experiences. Students and student clubs may work with Collection Committee when planning such events. The Committee can help guide the planning process, provide funding, and help raise awareness about such events.
Now, First Collection in particular has been an event at which the community–students, faculty, and staff–can come together to welcome the newest members of our community, and this year is no exception. The First Collection event now consists of a breakfast social. There will be a variety of breakfast goodies, as well as friendly faces new and old. While attendance may no longer be mandatory, it is an event you should definitely stop by for. First Collection is happening this Friday, November 1st, from 9:30 until 11 am, and will be held in the Sunken Lounge in the Dining Center Lobby. Be thyself collected therein!
If you're interested in joining the committee, applications were just sent out by the SC VP's! Make sure you send them in by Friday night at 11:59pm. For more information on what the committee does, check out the SC Appointments Descriptions Page: sc.haverford.edu/appointed-representatives/committee-descriptions-contacts/.


text:
KUMC uses the guidelines set by the State of Kansas for the Official Hospitality Reimbursements. The policy, #3351, is located at the Division of Accounts and Reports Policy and Procedure Manual website.
Effective April 18, 2008, Official Hospitality for meals will only be reimbursed at the current subsistence meal
rate for state employees. The fiscal year 2016 rates are: Breakfast $9.00, Lunch $12.00, and Dinner $25.00.
This rate will be allowed for each person present for the official hospitality (excluding spouses of state
employees). Expenses over the allowed rate will not be paid using state funds. No alcohol or tax on alcohol
will be allowed.
Department will:
NOTE: If you do not have an APP account, but you do have General Use Funds or Research Overhead Funds, please contact the Budget Office for them to assist you on setting up an APP account.