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Caparros, Alyssa Camille S. BSN, RN, PCCN, MSN-AGACNP-BC; Forbes, Alison MSN, ACNP-BC, CCRN
Alyssa Camille S. Caparros, BSN, RN, PCCN, MSN-AGACNP-BC, received her BS Nursing degree on 2008 from the Philippines. She is currently working at UCLA Medical Center as a registered nurse. She has been working as a nurse for 5 years now, moving around different acute care areas such as medical surgical, telemetry stepdown, and ICU. Her experience evolve around adult and gerontology care and interest in cardiopulmonary patients. She is a recent graduate from California State University Los Angeles with a degree in MSN AGACNP.
Alison Forbes, MSN, ACNP-BC, CCRN, works as clinical faculty at California State University Los Angeles, and ACNP in Trauma/Acute Care Surgery at Harbor UCLA Medical Center.
The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Address correspondence and reprint requests to: Alyssa Camille S. Caparros, BSN, RN, PCCN, MSN-AGACNP, California State University Los Angeles, 5151 State University Dr, Los Angeles, CA 90032 (firstname.lastname@example.com).
Background: Saline instillation in suctioning mechanically ventilated patients remains a common practice in the intensive care unit (ICU). Many respiratory therapists and nurses are using saline with suctioning without an adequate knowledge of the current evidence-based research to guide this practice.
Objectives: The purpose of this study was to determine if this routine method is beneficial or harmful to the patients and provide evidence-based practice recommendations that will serve as a guide for practice.
Methods: This is a comprehensive review on the use of saline instillation in suctioning mechanically ventilated adult ICU patients. Database such as CINAHL, MEDLINE, Cochrane, PsycINFO, and national guidelines are extracted for the review of literature. The study population consists of patients 18 years or older, who are intubated or have a tracheostomy in place, requiring mechanical ventilation, and who are admitted in the ICU.
Results: Although most of the evidence suggests not to use saline when suctioning, there are various limitations to the studies such as small sample size, settings, inconsistencies in data collection, or not enough or outdated research clinical trials, which calls for further studies.
Conclusion: This study does not support the use of saline instillation when suctioning an artificial airway. Further clinical trials are crucial to effectively determine if saline instillation use with suctioning an artificial airway is deemed harmful, which can be strictly enforced as a mandatory clinical guideline for all hospitals to include in their standardized protocol to not use saline instillation with suctioning.
Respiratory failure is one of the most frequent causes of admission or longer stay in acute care settings. It is usually accompanied by a variety of medical problems, such as stroke and other neurological conditions, cardiovascular disease, and respiratory disorders. Patients with acute respiratory failure require urgent medical attention by the health care team to prevent further deterioration that can eventually lead to mortality. With medical advancement, mortality can be prevented if interventions are quickly and properly provided. Endotracheal tube (ETT) intubation and tracheostomy tube (TT) are the most commonly used advanced artificial airways in managing respiratory failure. Intubated or tracheostomy patients are placed on a mechanical ventilator. These patients are critically ill and require close monitoring by the health care providers and are usually transferred to the intensive care unit (ICU) for further management. The nurses who are providing direct care to patients on mechanical ventilation (MV) carefully assess for signs of respiratory complications such as ventilator-associated pneumonia (VAP). Oral suctioning and tracheal suctioning are crucial nursing interventions to prevent VAP. Hemodynamic changes can also occur during suctioning of these patients. Nurses provide judicious patient care, and they monitor for any changes in the patient's status so they can quickly and accurately respond to any situations that may arise.
It is important to assess the ability to secure the airway of the patient in managing acute and life-threatening conditions or injuries. Artificial airways such as endotracheal tube and TT are placed when there is compromised ventilation.1
Endotracheal tube intubation is performed during emergency situations such as acute respiratory failure or inability of the patient to maintain a patent airway. Endotracheal tube intubation requires a cricoid pressure by placing the thumb and the index fingers on the cricoid cartilage. This will compress the esophagus to reduce the risk for gastric aspiration during the intubation.1 The ETT is placed by a qualified provider, and placement is confirmed by a chest radiograph. The ETT balloon should be inflated that is enough to provide a seal and secure the airway, and the pressure should not exceed 15 to 25 mm Hg, which can be measured by using the cuff manometer.1
The internal diameter of the ETT is 8 to 9 mm for men and 7 to 8 mm for women. The end of the inserted ETT is positioned at 2 cm above the carina, the site of tracheal bifurcation.1 Securing the ETT is critical when placement is verified, to prevent from dislodging or moving.1 Endotracheal tube placement is assessed by the nurses and the respiratory therapists (RTs) every shift or in accordance to the hospital protocol.
A tracheostomy is a surgical opening of the tracheal anterior wall through the neck area. This opening is made at the second or third cartilaginous ring level and is kept patent by inserting a TT. Indications for placing a permanent TT are (a) to maintain the airway because the normal mechanism to maintain the airway has been compromised, (b) to facilitate long-term means of ventilatory support for patients with respiratory failure by MV, (c) elective or emergency surgery for tracheostomy placement for head or neck trauma, and (d) to minimize the risk of aspiration from inability to swallow or absence of the laryngeal reflex.2
The type and size of the TTs depend on the patient's needs, reasons for placement, and the size of the patient's trachea. Tracheostomy tubes can be disposable or nondisposable. Caring for this patient population is based on managing the airway while maintaining the safety of the patients and preventing complications. Patients with a TT are not able to talk or make any sound because the TT is placed beneath the vocal cords. A speaker valve can be used after passing speech therapy evaluation for any risk of aspiration.2 In acute care setting, most patients with TTs have disposable inner cannulas, which are changed every shift and as needed depending on the secretions. For nondisposable TTs, a tracheostomy kit can be used to clean the inner tube. Tracheostomy care is done by the nurses or RTs depending on the hospital policy, and the tracheostomy site should be assessed regularly.
Mechanical ventilation is one of the most common interventions in the ICU. It is a supportive intervention used until the underlying physical issue has been resolved. Patients on MV decrease their work of breathing, relieve respiratory distress, rest the fatigued respiratory muscles, improve ventilation, stabilize the chest wall, and restore the acid-base balance.3
Patients on MV have the potential to develop hemodynamic instability. The need for MV is the patient's common feature requiring admission to the ICU.4 Choosing settings for MV requires balance between oxygen delivery, removal of carbon dioxide, and prevention of respiratory injury related to trauma. Inappropriate and inaccurate ventilatory support strategy can result to increase mortality. Therefore, many ventilatory techniques have been presented in standardizing the selection process of the ventilation settings (Table).5
Many hospitals have implemented standard order sets and guidelines in managing MV. Respiratory therapists are the experts in providing respiratory care to patients. They have the extensive knowledge on many pathophysiologies that necessitate MV and the pharmacology used in managing ICU patients who are mechanically ventilated. Respiratory therapists are competent in controlling MV settings and are also able to interpret laboratory results and make appropriate adjustments that affect the care of these patients.7 They have the capability to develop and implement guidelines that support the application of MV management. They assess the patients for any deviation and monitor for signs of respiratory distress and are prepared for any sudden change in the patient's respiratory status and apply appropriate and rapid measures in managing potential acute events. Physicians, nurses, RTs, physical therapists, care assistants, and other allied health care personnel work as a team in providing care to these patients.
This requires disconnecting the ETT or TT from the mechanical ventilator, which can result in significant loss of lung volume, and is followed by applying the suction that can further exacerbate the derecruitment of the lungs.8
Disconnecting the ETT or TT from the mechanical ventilator is not required, allowing for a continued tidal volume delivery and minimize lung volume loss. Closed suctioning is recommended in patients with acute lung injury or acute respiratory distress syndrome because they can have alveolar derecruitment that can be seen during suctioning the patients.8
Suctioning is important in maintaining patency and managing tracheal secretions. Tracheal suctioning can be distressing for the patients and can cause hemodynamic changes such as hypoxemia, arrhythmias, atelectasis, tracheal mucosal injury, bleeding, and infection.2
Ventilator-associated pneumonia is the most common hospital-associated infection in mechanically ventilated patients. Incidence currently ranges from 2 to 22 episodes per 1000 ventilator days. Ventilator-associated pneumonia mean incidence is 2.8 in the United States.9 Ventilator-associated pneumonia is defined as a type of hospital-acquired pneumonia that occurs in patients that are on MV support at the time of the diagnosis of pneumonia or within 48 hours of having been placed on MV.10
Ventilator-associated pneumonia pathogenesis involves aspiration of the bacterial organisms from the oropharynx into the lungs and subsequently causes failure of the defense system of the patients in clearing the bacteria, which leads to the development of a lung infection such as VAP.11
Mechanical ventilation for airway support can be a source of infection. It is an important part in intensive care provision for patients who are acutely and critically ill. Although it is beneficial to patients, it can impair the clearance of mucociliary process, causing retention of secretions, occlusion of the airway, atelectasis, and pneumonia.12 Aspiration of orapharyngeal secretions that are contaminated can lead to the development of VAP. These secretions pool above the TT cuff and eventually enter into the lower respiratory tract through the leaking around the cuff of the TT.9
Ventilator-associated pneumonia can worsen gas exchange, increase the load of secretions, and can potentially lead to deterioration of the function of other body organs such as the heart. Complications can delay the weaning process, prolong hospital stay, and increase mortality, which can result in higher costs of health care. Ventilator-associated pneumonia is associated with increase in morbidity, MV duration, and length and cost of stay in the hospital. Most hospitals have developed clinical preventive care strategies called the "care bundles," which showed effective reduction rate in VAP. Many preventive measures such as oral care routine with an antiseptic solution and elevation of the head of the bed are being implemented to prevent VAP. Chlorhexidine oral decontamination is also a widely researched strategy that can help in preventing VAP.9,13
Ventilator-associated pneumonia prevention is a priority to improve patient care and safety. There is a high morbidity and mortality rate that is associated with VAP and in an effort to address this issue, the Centers for Disease Control and Prevention has developed a guideline for preventing VAP. Ventilator-associated pneumonia bundles were implemented to help reduce the incidence of VAP.14
Ventilator-associated pneumonia is suspected clinically based on the presence of elevated temperature more than 38.3o C, white blood count more than 10000/mm3 or less than 4000/mm3, purulent secretions, new or persistent pulmonary infiltrate in the chest radiograph, and positive sputum culture and gram stain.10
There are many bacterial pathogens that can cause respiratory infections. The major potential respiratory bacterial organisms include Pseudomonas aeruginosa, Staphylococcus aureus, Acinetobacter species, and enteric species.11 A specimen sample from the lower respiratory tract is obtained when VAP is suspected. This involves a specimen collection through suctioning the ETT or TT by using a sterile suction catheter. The specimen is withdrawn and sent to the laboratory for quantitative bacteriology. The presence of more than 10000 colony-forming units per milliliter of target pulmonary respiratory pathogens in minibronchoalveolar lavage fluid or a positive culture is considered to be a positive finding for the diagnosis of VAP.11 As soon as the sputum culture identifies a pathogen and not colonization, specific antibiotic treatment should be initiated.15
The presence of pulmonary infiltrates that are not symmetrical on a chest radiograph that is consistent with VAP may be sometimes caused by other noninfectious conditions. However, some chest radiograph findings such as fast cavitation of pulmonary infiltrate that is progressive, air space process that is joining a fissure, bronchogram that is a single air are associated with 96% specific for VAP diagnosis and can be used reliably.10
The purpose of this study was to determine if the routine method of saline instillation prior to suctioning the mechanically ventilated patients is beneficial or harmful to patients. In addition, our goal was to provide evidence-based practice recommendations that will serve as a guide for nursing and respiratory care practice.
A comprehensive review on the use of saline instillation in suctioning mechanically ventilated adult ICU patients was conducted using databases such as CINAHL, MEDLINE, Cochrane, PsycINFO, and national guidelines for the review of literature. Materials reviewed included only studies of patients 18 years or older, who are intubated or have a tracheostomy in place, requiring MV, and who are admitted in the ICU.
Extensive efforts are underway to reduce VAP, which significantly increases the total number of ventilator-dependent days, overall mortality, and medical costs. Evidence-based research studies were analyzed on aspects of caring for the mechanically ventilated patients, including the use of saline installation in general and specialty ICU populations in international settings. Recently, Mei-Yu et al16 conducted an evidence-based research study approach to examine the relationship of saline instillation and VAP in the ICU. Ventilator-associated pneumonia incidence rates were compared between patients receiving normal saline instillation (NSI) and patients who did not receive NSI with ETT suctioning. Data on NSI use were gathered for 6 months and followed by data collection without using NSI. It was found that the VAP incidence rate on NSI use with suctioning is statistically significant. Not using NSI was found to decrease VAP incidence rate significantly.16
This concept is consistent with and supported by earlier work by Hagler and Traver,17 who found that a 5-mL NSI dislodged up to 310000 of viable colonies of bacteria. The potential risk for infection that is caused by dislodging the bacteria into the lower respiratory tract is added evidence that the routine use of NSI when suctioning should not be performed.17
Conversely, Caruso and colleagues18 conducted a randomized clinical trial in a closed medical surgical ICU in a tertiary oncology hospital. Patients were divided into 2 groups. The first group used suctioning without saline (control group), and the second group used 8 mL of isotonic solution instilled prior to each tracheal suctioning (saline group). In this study, the instillation of an isotonic saline prior to tracheal suctioning reduced the occurrence of microbiologically proven VAP. The rates of ETT occlusion and atelectasis were similar between the 2 groups.18
This study prompted debate as Kleinpell19 provided a commentary about Caruso and colleagues' study findings, noting that evidence from a vast number of research studies showed that the routine use of NSI prior to suctioning is not a recommended practice for mechanically ventilated patients. The findings from Caruso and colleagues are significantly different from the results of other studies and must be cautiously interpreted because of a number of limitations, such as the use of an oncology patient population that are different from the general ICU patients with regard to the occurrence of VAP, pretreatment of antibiotics, immunosuppression, and mortality. Kleinpell calls for further research before this practice can be recommended for routine use in ICU patients.
Normal saline instillation in preparation to suctioning the airway is commonly used to help remove thick respiratory secretion; however, Christensen et al20 report that the use of saline can damage the antimicrobial properties of the respiratory secretions. Their findings suggest that nasal and tracheal secretions and saliva have natural antimicrobial properties that can be damaged by instilling concentrations of sodium and chloride in the normal saline.20
Maggiore and colleagues21 discuss the risk for alteration in hemodynamics during suctioning with NSI that may result in complications, mainly oxygen desaturation and bloody secretions. Normal saline instillation can be used in open or closed suctioning and has been used by the health care professionals who believed it would increase the yield of the sputum by diluting and loosening the secretions, stimulate the cough, and lubricate the suction catheter. However, studies are conflicting about the safety and efficacy of using NSI contrary to these common beliefs.22,23
It is believed that it can result to hypoxemia, bronchospasm, cardiac and respiratory arrest, infection, and no improvement in oxygenation or secretion yield.23 A recent systematic review23 aimed to investigate the safety and efficacy of NSI technique prior to airway suctioning. It was found out that there is no evidence that NSI is harmful to the patients based on hemodynamic changes, gas exchange, increased dyspnea, or respiratory distress. Although there was some weak research result linking the use of NSI and VAP, further methodological research studies are warranted.23
Rauen and colleagues24 found in most experimental studies that SPO2 was significantly decreased with NSI, or there is no difference in SPO2 with NSI and no saline use. One interesting finding that they found in their systematic review was that there were some indications of a reduction in SPO2 after NSI prior to suctioning, and the return to baseline SPO2 levels did not occur until at least 3 to 5 minutes after the suctioning was completed.24
In regard to secretions, although there is a claimed benefit of NSI in the improved secretion removal, Rauen et al report that there are no adequately reported research studies to support this practice. This is partly due to the problems that are associated with the methodological process with the measuring of the secretion amounts in clinical research studies, which calls for further studies to find out the best way to quantify the amount of secretion removal when using NSI prior to suctioning.24
These recent studies contradict earlier work, in 1990 when Gray et al25 reported that NSI resulted in an enhanced clearance of secretions by stimulating the cough, and the effects on hemodynamics, respiratory mechanisms, exchange of gas, and patient comfort were not significantly different compared to suctioning without NSI. Similar result was reported in a small group of intubated adult patients when NSI was done during chest physiotherapy and resulted in an increased sputum weight and no adverse effects on SPO2.26
A recent study from the British Journal of Nursing also reports that NSI with suctioning mechanically ventilated patients appears to remove a greater amount of respiratory secretions compared to not using NSI. However, the study cautions that this finding is considered controversial because the increase in weight of the suctioned secretions can be attributed to the NSI.27
One study in 200128 compared the level of dyspnea with and without using a 5-mL NSI before ET suctioning using a crossover, quasi-experimental study design. Using the vertical visual analogue scale, patients (17 alert adults who are mechanically ventilated) were asked to rank their dyspnea level. Saline was randomly instilled before 1 of 2 suctioning. This study showed no beneficial effects of using saline. However, it demonstrated that NSI precipitated a significant increase in the level of dyspnea up to 10 minutes after suctioning in patients older than 60 years.28
Maggiore and colleagues found that ET suctioning can cause decrease in SPO2 by 5%, trauma or bleeding with blood visible in suctioning secretions, increased blood pressure to 200 mm Hg or decreased blood pressure to 80 mm Hg, increased heart rate (HR) to 150 beats/min or decreased HR to 50 beats/min, and arrhythmias such as supraventicular or ventricular tachycardias.21
Iranmanesh and Rafiei29 studied the effect of NSI on the SPO2, HR, and cardiac rhythm of multiple trauma patients. A crossover design was conducted with 50 multiple trauma patients who were admitted to ICU and were mechanically ventilated for more than 24 hours. Subjects were selected randomly to suctioning with or without the use of NSI. Results indicated that NSI when suctioning can cause potential adverse effects on SPO2, but results in no effect on the HR or cardiac rhythm. Educational programs should be provided to the nurses and RTs to help improve their knowledge on the disadvantages of using NSI when suctioning an artificial airway.29
The national guidelines from the American Association for Respiratory Care30 provide recommendations on ET suctioning. These include (a) suction the ET only when there are secretions present; (b) preoxygenate the patients with decreased SPO2 when suctioning; (c) do not disconnect the patient from the mechanical ventilator when suctioning; (d) use shallow suctioning than deep suctioning; (e) use closed suctioning for adult patients with high FIO2 or positive end-expiratory pressure, or those at risk for lung derecruitment; (f) routine use of NSI before ET suctioning is not recommended; and (g) suctioning duration should be limited to less than 15 seconds.30 The Agency for Healthcare Research and Quality updates the current guidelines (the previous version of the American Association for Respiratory Care clinical practice guidelines)31 to include similar recommendations and interventions such as preoxygenation, shallow suctioning technique, sterile technique during open suctioning, using lung recruitment maneuvers, suction duration of less than 15 seconds, and monitoring of the patient.31 It is also noted that deep suctioning and NSI prior to ET suctioning may be considered but are not recommended. The report cautions that NSI is hypothesized to loosen secretions, increase the amount of secretion removal, and help in the removal of tenacious secretions. However, evidence is lacking to support this. The majority of the studies used to update this current guideline indicate that NSI is not likely to be beneficial and may be harmful to the patients. Therefore, NSI with suctioning is not recommended to be routinely performed, and the potential danger of the routine use of NSI may be associated with adverse events such as excessive coughing, decreased SPO2, bronchospasm, tachycardia, pain and dyspnea, and increased intracranial pressure.31
The guidelines on routine practice of suctioning mechanically ventilated patients are not consistent with routine use of saline instillation, as the efficacy of NSI is not supported by research-based evidence. This practice may provide no physiological benefits and may have effects that can be detrimental.32 However, NSI continues to be used in practice and requires additional study to establish its safety and effectiveness. Although the use of NSI is a routine clinical practice in some ICUs, its negative effects and questionable benefits on the amount of suctioned secretions should encourage the nurses or RTs to not apply this technique and reconsider the practice and should not be a routine method in suctioning patients with an artificial airway for removal of respiratory secretions.27
Maggiore and colleagues21 follow clinical guidelines for ETT suctioning, as the use of NSI is avoided. They recommend a heated humidifier for patients with dry and tenacious secretions. If mucous plug is suspected, suctioning under the direct visualization of fiberoptic bronchoscopy should be performed.21
Rauen and colleagues24 also support these national guidelines and report that recent evidence provides a unanimous recommendation that NSI should not be a routine practice with suctioning.
Patients on MV are at high risk for many complications such as infection (ie, VAP) and hemodynamic changes. Clinical routine practice of NSI with suctioning an artificial airway is being done on a daily basis without having a clear evidence-based clinical guideline to support its practice. This can cause many potential complications especially to those patients who are already critical or unstable in terms of their medical conditions. This study found out that suctioning an artificial airway with the use NSI can pose great risks to the patients. It can cause complications such as VAP and hemodynamic changes that are not favorable to the patients' recovering process. This review does not endorse the use of NSI when suctioning a patient with an artificial airway. Education should be provided to every health care provider regarding the effects of using NSI when suctioning and how it can cause further harm to the patients. It is prudent advice from researchers such as Rauen and colleagues, who reminds us that there is no credible and scientific research information that supports this practice. There are no known studies that have shown that NSI is beneficial, and in addition to its lack of theoretical benefits, researchers found it to be detrimental to the patients.24
Implementing clinical guidelines is crucial in order to maintain the safety of all patients. Although most of the evidence suggests not to use NSI when suctioning, there are various limitations to the studies done such as small sample size, settings, inconsistencies in data collection, or not enough or outdated research clinical trials, which calls for further research studies. Therefore, extensive clinical trials are recommended to effectively determine if NSI with suctioning an artificial airway is indeed harmful, and adherence to national clinical guidelines should be strictly enforced nationwide for all hospitals to include in their standardized protocol to not use NSI with suctioning.
I would like to extend my deepest gratitude to all the people who have helped me with this paper. First, I would like to thank my professor, Dr Thomas Barkley, for being a great mentor and an advocate for ACNP students. Thank you for helping me structure my research topic and for guiding me with writing this article. I would like to thank my clinical instructor, Alison Forbes, ACNP, who served as my advisor, assisting me with the revision and provided comments on how to better organize my article. I would also like to thank Kevin Quinonez, RT, for being an expert with regard to respiratory care and provided his professional and own personal stance about the article. Lastly, I would like to express my warmest appreciation to the editor-in-chief of the DCCN journal, Kathleen Ahern Gould, PhD, RN, for the professional feedback and the guidance to make this article possible.
Mechanical ventilation; Saline instillation; Suction
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text:
Supply of power at medium voltage (full page)
From Electrical Installation Guide
In this chapter, networks which operate at 1000 V or less are referred to as low-voltage (LV) networks, whereas networks requiring a step-down transformer to feed LV networks are referred to as medium voltage (MV) networks.
| (1) According to the IEC there is no clear boundary between medium and high voltage; local and historical factors play a part, and limits are usually between 30 and 100 kV (see IEV 601-01-28).The publication IEC 62271-1 "High-voltage switchgear and controlgear; common specifications" incorporates a note in its scope: "For the use of this standard, high voltage (see IEV 601-01-27) is the rated voltage above 1 000 V. However, the term medium voltage (see IEV 601-01-28) is commonly used for distribution systems with voltages above 1 kV and generally applied up to and including 52 kV."
Power supply characteristics of medium-voltage networks
The main characteristics of an MV power supply are:
The characteristics of the MV network determine which switchgear is used in the MV or MV/LV substation and are specific to individual countries. Familiarity with these characteristics is essential when defining and implementing connections.
Different types of MV power supply
The following power supply methods may be used as appropriate for the type of medium-voltage network.
Connection to an MV radial network: Single-line service
The substation is supplied by a tee-off from the MV radial network (overhead or cable), also known as a spur network. This type of network supports a single supply for loads (see Fig. B1).
The substation usually consists of an incoming panel, and overall protection is provided by a load-break switch and fuses with earthing switches as shown in Figure B1.
In some countries, the "substation" comprises a pole-mounted transformer without a load-break switch or fuses (installed on the pole). This type of distribution is very common in rural areas. Protection and switching devices are located remotely from the transformer. These usually control a main overhead line to which secondary overhead lines are connected.
Fig. B1: Single-line service (single supply)
Connection to an MV loop: Ring-main service
The power supply for the substation is connected in series to the power line of the medium-voltage distribution network to form a loop(1). This allows the line current to pass through a busbar, making it possible for loads to have two different power supplies (see Fig. B2).
The substation has three medium-voltage modular units or an integrated ring-main unit supporting the following functions:
- 2 incoming panels, each with a load-break switch. These are part of the loop and are connected to a busbar.
- 1 transformer feeder connected to the busbar. General protection is provided by load-break switches, a combined load-break/isolating switch or a circuit breaker.
All these types of switchgear are fitted with earthing switches.
All switches and earthing switches have a making capacity which enables them to close at the network's short-circuit current. Under this arrangement, the user benefits from a reliable power supply based on two MV feeders, with downtime kept to a minimum in the event of faults or work on the supplier network(1).
This method is used for the underground MV distribution networks found in urban areas.
Fig. B2: Ring-main service (double supply). The transformer is protected, in accordance with the applicable standards, by a circuit breaker or load-break switch as shown in Figure B1.
Connection to two parallel MV cables: Parallel feeders service
If two parallel underground cables can be used to supply a substation, an MV switchboard similar to that of a ring-main station can be used (see Fig. B3).
The main difference to the ring-main station is that both load-break switches are interlocked. This means that only one of them can be closed at any one time (if one is closed, the other must be open).
In the event of the loss of supply, the associated incoming load-break switch must be open and the interlocking system must enable the switch which was open to close. This sequence can be implemented either manually or automatically.
This method is used for networks in some densely-populated or expanding urban areas supplied by underground cables.
Fig. B3: Parallel feeders service (double supply). The transformer is protected, in accordance with local standards, by a circuit breaker or load-break switch as shown in Figure B1.
Some practical issues concerning MV distribution networks
Overhead networks
Weather conditions such as wind and frost may bring wires into contact and cause temporary (as opposed to permanent) short-circuits.
Ceramic or glass insulating materials may be broken by wind-borne debris or carelessly discharged firearms. Shorting to earth may also result when insulating material becomes heavily soiled.
Many of these faults are able to rectify themselves. For example, damaged insulating materials can continue functioning undetected in a dry environment, although heavy rain will probably cause flashover to earth (e.g. via a metallic support structure). Similarly, heavily soiled insulating material usually causes flashover to earth in damp conditions.
Almost invariably, fault current will take the form of an electric arc, whose intense heat dries the current's path and, to some extent, re-establishes insulating properties. During this time, protection devices will normally have proved effective in eliminating the fault (fuses will blow or the circuit breaker will trip).
Experience has shown that, in the vast majority of cases, the supply can be restored by replacing fuses or reclosing the circuit breaker.
As such, it is possible to improve the service continuity of overhead networks significantly by using circuit breakers with an automated reclosing facility on the relevant feeders.
These automated facilities support a set number of reclosing operations if a first attempt proves unsuccessful. The interval between successive attempts can be adjusted (to allow time for the air near the fault to deionise) before the circuit breaker finally locks out after all the attempts (usually three) have failed.
Remote control switches can be used on cable segments within networks to further improve service continuity. Load-break switches can also be teamed with a reclosing circuit breaker to isolate individual sections.
| (1) A medium-voltage loop is an underground distribution network based on cables from two MV substation feeders. The two feeders are the two 'ends' of the loop and each is protected by an MV circuit breaker.
The loop is usually open, i.e. divided into two sections (half- loops), each of which is supplied by a feeder. To support this arrangement, the two incoming load-break switches on the substations in the loop are closed, allowing current to circulate around the loop. On one of the stations one switch is normally left open, determining the start of the loop.
A fault on one of the half-loops will trigger the protection device on the associated feeder, de-energising all substations within that half loop. Once the fault on the affected cable segment (between two adjacent substations) has been located, the supply to these substations can be restored from the other feeder.
This requires some reconfiguration of the loop, with the load-break switches being switched in order to move the start of the loop to the substation immediately downstream of the fault and open the switch on the substation immediately upstream of the fault on the loop. These measures isolate the cable segment where the fault has occurred and restore the supply to the whole loop, or to most of it if the switches that have been switched are not on substations on either side of the sole cable segment affected by the fault.
Systems for fault location and loop reconfiguration with remote control switches allow these processes to be automated.
Underground networks
Cable faults on underground networks can sometimes be caused by poorly arranged cable boxes or badly laid cables. For the most part, however, faults are the result of damage caused by tools such as pickaxes and pneumatic drills or by earthmoving plant used by other public utilities.
Insulation faults sometimes occur in connection boxes as a result of overvoltage, particularly at locations where an MV network is connected to an underground cable network. In such cases, overvoltage is usually caused by atmospheric conditions, and the reflection effects of electromagnetic waves at the junction box (where circuit impedance changes sharply) may generate sufficient strain on the cable box insulation for a fault to occur.
Devices to protect against overvoltages, such as lightning arresters, are often installed at these locations.
Underground cable networks suffer from fewer faults than overhead networks, but those which do occur are invariably permanent and take longer to locate and resolve.
In the event of a fault affecting an MV loop cable, the supply can be quickly restored to users once the cable segment where the fault occurred has been located.
Having said this, if the fault occurs at a feeder for a radial supply, it can take several hours to locate and resolve the fault, and all the users connected in a single branch arrangement downstream of the fault will be affected.
In cases where service continuity is essential for all or part of the installation concerned, provision must be made for an auxiliary supply.
Remote control and monitoring for MV network
|The use of centralised remote control and monitoring based on SCADA (Supervisory Control And Data Acquisition) systems and recent developments in digital communication technology is increasingly common in countries where the complexity associated with highly interconnected networks justifies the investment required.
Remote control and monitoring of MV feeders makes it possible to reduce loss of supply resulting from cable faults by supporting fast and effective loop reconfiguration. This facility relies on switches with electric controls which are fitted on a number of substations in the loop and linked to modified remote-control units. All stations containing this equipment can have their supply restored remotely, whereas other stations will require additional manual operations
Values of earth fault currents for MV power supply
The values of earth fault currents on distribution networks depend on the MV substation's earthing system (or neutral earthing system). They must be limited to reduce their impact on the network and restrict possible increased potential on user substation frames caused by the coupling of earth switches (overhead networks), and to reduce flashover with the station's LV circuits capable of generating dangerous levels of potential in the low voltage installation.
Where networks have both overhead and underground elements, an increased cable earthing capacitance value may cause the earth fault current value to rise and require measures to compensate this phenomenon. Earthing impedance will then involve reactance (a resistor in parallel with an inductor) in line with the leakage rate: the neutral earthing system is compensated. Compensatory impedance makes it possible to both:
- Control earth fault current values, regardless of the amount of cabling within the network, and
- Eliminate most temporary and semi-permanent single-phase faults naturally by facilitating self rectification, thereby avoiding many short-term losses

subset: commoncrawl


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Presentation by Vincent J. Del Casino, Jr., Associate Dean, College of Social and Behavioral Sciences; Professor of Geography and Development, University of Arizona
"Data demonstrate that the world's human population is getting older as life expectancy continues to increase globally. Much of this increase is taking place in the so-called developing world. Despite these trends, there remains tremendous variability in the geography of life expectancy. There are in fact points in time and place where life expectancies have dropped or will drop in the future. We are just beginning to understand, what the "new longevity" means for society as we adapt our social welfare systems to the changing demographics of our aging populations. Where will our aging populations live? Who will care for them? How are the roles of older populations changing? Aging will continue to present new challenges as our global population reaches toward 9 billion over the next 40 years. To better respond to the needs of our world's changing demographic distributions, it is critical that we understand the nature of aging at both global and local scales today." - UA College of Science


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Could Juanita Beach Open August 6th?/
[box type="note" style="rounded" border="full"]A reader asked this question of the City and shared the response with us. - Editor[/box]
Q: When will Juanita Beach Park reopen?
A: We get asked this question more than any other - at least once a week. Positive news comes our way compliments of Eric O'Brien, a reader of Kirkland Views. It appears that significant progress has been made to the park and that the City will soon announce an opening date for the beach -- possibly as soon as August 6th. Eric has shared the following correspondence with the Parks Department.
Dear Editor:
I was impressed that Jenny [Schroder] took the time to give me a detailed update on the project. Equally impressed with the progress Marshbank has made in the park over the past few weeks.
Eric O'Brien
Hi Jennifer,
Is there a project plan for the completion of the Juanita Beach Park renovation project? All I've heard is "As soon as possible" or "Hopefully before the end of summer". Is there at least an estimated date the public can use the park again?
Thank You, Eric O'Brien
Hi Eric, as promised I have another update for you,
Major activity this last week has been restoring the beach area. Up to six workers each day since Monday have cleaned, grubbed/weeded, and re-graded the sandy beach (which in length is equivalent to two and a half football fields). A significant undertaking considering that the beachfront has been left essentially unattended for the past 14 months. Most of this task is now complete – the beach looks great - and the workers will now turn their efforts towards preparing the site for planting, seeding, and installation of sod.
Landscaping, electrical, paving/curbing/striping, carpentry, and concrete subcontractors have all been secured for the project and will now begin to mobilize. We will be seeing some of them on site next week, with a particular emphasis on soil prep in lawn and landscape beds. Several hundred cubic yards of topsoil and organic mulch will be heading our way.
Monday the contractor will confirm a date for the beach opening, It may be as early as August 6th. We will have a press release once a date is confirmed.
Have a good weekend, - jenny
Jennifer Schroder, CPRP
Parks and Community Services Director


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Elizabeth Margaret Burch, 39, enjoyed a comfortable life in a large house in the sunny suburbs of Ashford, Kent. In 1893, she had been the fortunate beneficiary of a substantial inheritance that had come her way quite by chance. Five years previously whilst living in South Kensington, Elizabeth had been amongst a crowd in St James's Park awaiting the arrival of the ladies to Buckingham Palace, when an elderly gentleman, near to where she was standing, had fainted in the heat. She had rushed to his aid with a glass of water. When the gentleman died, some years later, his solicitors revealed that, having no relatives of his own, he had left his fortune of £150,000 (over 14 million in today's money) to his kindly rescuer. The heiress then moved to Ashford, where she dined on fine foods and wore the most fashionable clothes.
Grateful for her considerable fortune, Elizabeth decided to use her wealth to help those in need. Even before her windfall, she had saved her sisters from bankruptcy after their dressmaking business had failed. Leading by example, she used her newly-acquired position in Kent society to encourage donations from others for a number of charities, including the widows of the South Wales colliery explosion, the National Benevolent Institution and the Aged Pilgrims' Friendly Society. However, all of a sudden the Ashford Heiress disappeared without a trace.
A few months later, a new and distinguished visitor arrived on the scene in Manchester and began to mix in high-ranking social circles. Reticent about using her title of Lady Russell, she often used an alias when she was on business in town, but when she came to the notice of the ever-suspicious Detective Chief Inspector Caminada, he caught the very distinctive whiff of a scam. Jerome Caminada paid a visit to 'Lady Russell' at her lodgings and found the 'most stylishly attired' woman sitting at her writing desk, gold-rimmed spectacles perched on her nose as she bent to her task. On searching the room, the detective found a number of begging letters, as well as account books listing the donors to her charitable causes. He even uncovered a memo book interleaved with blotting paper that, although the pages had been removed, bore the indelible traces of the amounts of money received, which ranged from 1 shilling to 5 pounds. This consummate swindler was, in fact, Elizabeth Margaret Burch.
The Ashford Heiress was found guilty of obtaining money by false pretences and was sentenced to 6 months' imprisonment. She later admitted that the inheritance had been fake, although she had helped the gentleman in St James's Park. In an astonishing twist to the case, worthy of the pen of Sir Arthur Conan Doyle, in prison Elizabeth turned her talents to creative writing and although her previous existence had been a work of fiction, there is no evidence to suggest that she was as successful in her endeavour to become a writer.
I will be sharing stories from Detective Caminada's casebook at the Rochester Literature Festival on Monday 29 September, from 6.30 pm at the Dot Café. Tickets are available here. All welcome!


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May 12, 2006
Management of Spent Nuclear Fuel at the Savannah River Site
The Department of Energy's (Department) spent nuclear fuel Operations program at the Savannah River Site (Site) will likely require Extended H-Canyon to be maintained at least two years beyond defined operational needs. The Department committed to maintain H-Canyon operational readiness to provide a disposal path for degraded spent nuclear fuel, which may pose an immediate safety and health risk, until a treatment or packaging capability is available. However, as of January 2006, the Department had not approved a specific technology to prepare the Site's spent nuclear fuel for disposal.


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Tigers score 6 in 9th, beat White Sox in 12Once the Tigers sent the middle of their order up in the ninth against the White Sox bullpen, it looked like nothing they had seen. The Tigers entered the home half of the ninth trailing 6-0 thanks to their own bullpen and a stellar start by White Sox lef… (more)Source: ESPN.com
The Juice: Tigers overcome six run ninth inning deficit to top White SoxLess than two weeks to go in season No. 6 of the Juice! Stop by daily for news from the action, along with great photos, stats, video highlights and more. The Detroit Tigers lowered their magic number to two in the AL Central with an exhilarating 7-6 co…Source: yahoo.com
Improbable rally cuts Tigers' magic number to twoThe Tigers erupted for six runs in the ninth inning and tallied the game-winner in the 12th to pull off an improbable 7-6 win over the White Sox on Saturday night. The victory shaved Detroit's magic number to clinch the AL Central to two.Source: MLB.com


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Meet the Stars of the NHRA Mello Yello Series
Read full bios on all the series regulars, including major accomplishments, best runs, hobbies, and more, plus team and driver Twitter account info on the social media page.
NitroMall is your one-stop spot for official NHRA merchandise, products from some of the teams of the NHRA Mello Yello Drag Racing Series, and more. The NHRA Store is the place to join NHRA and purchase specialty items and DVDs, and the NHRA Museum Store has items to satisfy history buffs, from vintage T-shirts to historical books.
Well the first race of the season didn't quite turn out the way I had hoped. If you read the last blog, you saw that my car wasn't ready to go testing in West Palm Beach with the rest of the teams. The plan was to go test in Vegas on our way out to Pomona. We made it to Vegas with every intention to get some good laps under our belt, but when we got to Vegas the weather was not good. It was very cold. In fact, there were flurries there one of the days. We made two quick hits, but the car didn't like the cold temperatures, so we packed up and headed to Pomona.
Not being able to test put us behind at Pomona. We had a planned shut off for the first run, and struggled to figure out the right combination for the rest of the qualifying sessions. As you could see, it took your "A" game to qualify, and we were not ready to bring that to Pomona. I have a feeling this whole season will be a tough battle, and I am counting on Richard Hartman to get this car running competitively.
I wish I had more to update you all on, but there isn't much excitement when you DNQ the first race of the year. Hopefully we will have better results in Phoenix. In fact, I have a feeling there are going to be some pretty incredible times, because the weather is going to be cool. Anyway, to stay up to date with me and the team between blogs follow me on twitter @terrymcmillen, like me on Facebook www.facebook.com/terrymcmillenracing, or subscribe to my YouTube channel www.youtube.com/terrymcmillenracing!


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Released: Aug 18, 2009.
Genre: Progressive rock/indie.
Label: Triple Crown.
Number Of Tracks: 11.
From start to finish it delivers just the right kind of song at the right time and goes with the ebb and flow of things.
POSTED: 08/24/2009 - 04:57 am
Release Date: Aug 8, 2006.
Label: Triple Crown.
Genres: Indie Rock, Indie Electronic, Ambient Pop.
Number Of Tracks: 10.
On this CD they harness the creativity of '70s album rock, the lush tones of ambient pop, and the subtle passion of groups such as The Smiths from the late '80s.
POSTED: 12/07/2007 - 01:48 am


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iPhone | 1/3000 | f/2.8 | ISO 80 (who knew!)
"i"Phone that is! I saw this picture in the gallery before I even clicked on it and new it was "the one" today. And that apparently I am going to overuse quotation marks today as well.
Once I opened this and realized it was an iPhone pic, I thought it was perfect for the Daily Photo Fix given todays "rant" (self-proclaimed) on Photofocus today! And I totally love that he tagged the post "excuses". LOL Scott is da bomb. Da bomber of truths, that is!
Thank you to UKBecca for posting in the Flickr Group and allowing me to use four sets of quotation marks and twice use the phrase "that is"! If you'd like to submit images to our Flickr Group to be featured on the Daily Photo Fix:
1) Head over to Flickr… if you don't have an account, sign up for one. It's super easy.
2) Find our group: http://www.flickr.com/groups/thephotojunkies/
3) Join the group
4) Post pictures!


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How to get free stuff
How to visit the Isle of the Dead
How to make Freaky Objects
How to kill people lightly
How to paralyse people
How to fry Lord British's brain
The Grand Magical Duel
How to carry all things
How to create people
How to create a swift
The hedgehog song (with the gypsies)
Strange Things happened in Jhelom one day..
Hunting Without Bloodshed
Cloning things for Fun and Profit
The Madness of Minoc
How To Unlock Stubborn Doors
How to make torches
SPAM SPAM SPAM HUMBUGThis will access the Secret Cheater's Menu.
Anything you dial up from IOLO will NOT BE PERMANENT.
The items will stay indefinitely in your pocket, but when you drop them, they will vanish when you leave the area.
To make objects permanent, use 'SETTER.EXE' to lock all dropped objects. Make sure that there are no other temporary objects lying around, or they will be fixed as well.
Macbeth: Let me pour thee some ale, sire..
Lord British: STOP THIEF!!!
Macbeth: My liege? My liege..? Sire?!?
I went there once.. it's a strange land unfit for human habitation.
Fortunately the inhabitants are dead so it doesn't matter to them.
Here's how you can go to the afterlife yourself (with a hex editor):
Here are some more examples to be getting on with:
Killing people in cold blood using magic or weapons can have bad effects on their mental health.
Using a simple resurrection spell or a healer, you can raise the dead, but if they die fighting you, with hate in their minds, they vegetate.
Such people will never speak again, never walk or move again.
Effectively, they go brain dead.
We have discovered a way to work around this. If you kill someone with a cannon, they don't notice.(!)
They will not turn into vegetables, and will function fully when resurrected.
The same effect can be achieved using a Poison spell, or by pushing them into a fire.
We call this 'killing someone lightly', and any method will work as long as they do not realise they are being attacked.
If they scream when you attack them, that is bad, and you should wait until they calm down again before killing them, using some other means.
This is useful if you are landscaping Britannia, and need some staff for a castle etc.
Incidentally, I have written a program called 'UnDead' that attempts to fix all brain-damaged characters.
They must be lying dead on the floor.
Lord British will have become a vegetable, with the Bomb having collapsed his positronic brain.
You will notice he has become damaged in the battle, and lost the ability to speak.
You may notice an arrow at the bottom of the empty bag.
You must never ever scroll out the bottom of the empty bag.
If you do this, the game will lock solid.
For the QUALITY, give the NPC number of the person you want.
Use the TWEAK Database of Characters if you're not sure.
When you talk to the shrine it will act like that character.
I discovered Swift one day by getting Tiberius to resurrect the bones of Zog, although other skeletons will do the trick.
Digging up the graves outside Tiberius' house and getting him to resurrect each one is a good way to find it.
You will know when you have succeeded because Swift is automatically appended to your party.
You don't have to ask it to join.
Swift is a logical copy of the avatar, as far as its abilities are concerned.
However, it is also your vehicle.
If you have a swift and you travel by balloon or by ship, examining Swift will give you a picture of the ship, or the balloon.
Swift's physical appearance is variable, and it is set each time you leave a vehicle.
My personal favourite is when you leave a skiff, Swift will become a huge pile of 0 gold coins that is part of the party.
I always carry a skiff so I can do this.
AK: It's nice to know you're not wasting your time with this game..
JM: We figured all this out by about 1993, in the summer.
AK: In the summer?
AK: You should have been out in the fields, playing with sticks, not coercing virtual characters to engage in acts of bestiality!
In the normal process of the brawl, each attacks does no harm. However, one of the brawlers attacked Jamlid, and he decided to join in the brawl.
Jamlid assaulted his attacker in the belief that the game would limit him to 0 damage points like the other brawlers.
However, Jamlid's attacks did 20 damage points each. Then victim died.
Jamlid's kill began to upset the brawl engine, and all the brawlers were doing each other 4-5 points each blow, though they did not know it.
Jamlid left them brawling and went to get the local rune.
When he next entered the pub there was no-one left alive.
Now, how would you like to try this for yourself?
All you need is the Pickpocket spell.
Just pick the pocket of a Sheep, and you should see the leg of meat inside.
Select it, and the meat will fly out of the Sheep and into you hand.
The avatar removes all the meat from a deer at a distance
I'm surprised no one ever discovered this, but a friend of mine and I found this out the summer Ultima 6 came out: How to make a smegload of money, OR how to harass bar patrons: Both of these involve the same technique. First how to make money: 1. Drop a suit of magic armour outside the armourer in Trinsic. 2. Cast 'Animate' on the suit of armour. 3. Since it's now alive, it can easily be cloned. 4. Cast Clone until you don't have any MP left. 5. Wander around and KILL all the armours. 6. Pick them up and sell them for ungodly sums. Now to harass bar patrons: Another humourous technique is to animate lightning wands (or, glass swords). Clone them, and send them into the bar. Piss them off with a sling or something, and watch 'em go wild!
The Avatar, attempting to destroy what he has just created
The Object Editor
Poor Dupre ran into a horde of Vikings or fell under a bus, I can't remember which
Go into the savegame directory and make sure OBED.EXE is in this directory. Now type: OBED objblkcc
Now, highlight the Dead Body and press ENTER.
Press 7 (Change quality/tag) and enter 2 (Dupre's NPC number)
Now quit the editor (ESC,ESC) and save the changes.
Dupre will rise.. He will rise from the grave.. He will rise from the flames..
Throw the switch, Igor..
Short and to the point, the instructions are as follows:
But wait.. what's this?
Are you trying to open that pesky locked door that stands between you and someone else's hard-earned cash?
Can't find the key? Never mind.. where we're going, we don't need 'keys'.
Gunpowder is a fairly obvious solution, but it's too heavy to lug much around. Mass Death is my preferred way to remove stubborn stains, but it can be overkill. This method is energy-efficient and you don't need to be a master mage to pull it off.
In theory, (and in practice according to what I've heard) this should work on ANY locked door that can be cast upon, which can obviate several quests ;-)
These pages are maintained by my alter ego, DOUG the Eagle, a member of the UDIC, which is an Ultima Fan Group.
Back to the front page
Restart Frames


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Voters are good with alcohol being sold on Sundays at three more Lucas County businesses.
Local-option permit requests were approved Tuesday by a 208-89 vote for the Cinco de Mayo Amigos restaurant in Oregon, at 3111 Navarre Ave.; by a 142-52 vote for the Curtice HyFlash convenience store, at 7410 Jerusalem Rd. in Jerusalem Township, and by a 244-84 vote for the Majestic Oak Winery in Providence Township, at 13554 Mohler Rd.
Majestic Winery was seeking to sell wine and mixed beverages; the restaurant and convenience store had requested Sunday sales of both of those items plus the right to sell liquor.
In each case, the decision was made by a single, affected precinct.


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Tax deadlines upcoming
Helen R. Phillips, Upshur County assessor, wishes to remind all business property owners who have not been assessed for the 2014 tax year for property owned on July 1, 2013, to please do so by Sept. 1, 2013
Phillips also wishes to remind property owners whose land may or has previously qualified for "farm use" to make application by Sept. 1, 2013, to continue their qualification.
All landowners who qualified for 2013 tax year were mailed an application in July 2013. If you did not receive your application, please stop in the assessor's office to receive another copy.
To qualify for "farm use" a parcel less than 5 acres must sell $500 worth of products. A parcel with more than 5 acres must produce at least $1,000 in products sold, used and consumed on farm operation.
The assessor, by law cannot accept any "farm use" applications after the Sept. 1 deadline.


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Are these the best bars in Milwaukee?
The Esquire Network special "Best Bars in America" includes four Milwaukee establishments: the Knights Bar at Mader's, Holler House, Bryant's and Koz's Mini Bowl.
Sounds arbitrary to me. What do you think?
The program, intended to celebrate the 80th anniversary of the repeal of Prohibition, airs at 8 p.m. Thursday. It is hosted by comics Jay Larson and Sean Patton. »Read Full Blog Post(22)


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TheStreet Ratings Top 10 Rating Changes
You can view the full Martin Marietta Ratings Report or get investment ideas from our investment research center .
Rating Change #6
Buckeye Partners LP (BPL) has been upgraded by TheStreet Ratings from hold to buy. The company's strengths can be seen in multiple areas, such as its compelling growth in net income, good cash flow from operations, impressive record of earnings per share growth and notable return on equity. We feel these strengths outweigh the fact that the company has had lackluster performance in the stock itself.
- EXCLUSIVE OFFER: Jim Cramer's Protégé, Dave Peltier, only buys Stocks Under $10 that he thinks could potentially double. See what he's trading today with a 14-day FREE pass.
Highlights from the ratings report include:
- The net income growth from the same quarter one year ago has significantly exceeded that of the S&P 500 and the Oil, Gas & Consumable Fuels industry. The net income increased by 177.6% when compared to the same quarter one year prior, rising from -$109.70 million to $85.12 million.
- Net operating cash flow has significantly increased by 130.50% to $0.85 million when compared to the same quarter last year. In addition, BUCKEYE PARTNERS LP has also vastly surpassed the industry average cash flow growth rate of -15.43%.
- BUCKEYE PARTNERS LP reported significant earnings per share improvement in the most recent quarter compared to the same quarter a year ago. This company has reported somewhat volatile earnings recently. But, we feel it is poised for EPS growth in the coming year. During the past fiscal year, BUCKEYE PARTNERS LP reported lower earnings of $1.25 versus $1.93 in the prior year. This year, the market expects an improvement in earnings ($2.77 versus $1.25).
- BPL, with its decline in revenue, slightly underperformed the industry average of 7.2%. Since the same quarter one year prior, revenues fell by 13.5%. The declining revenue has not hurt the company's bottom line, with increasing earnings per share.
- Current return on equity exceeded its ROE from the same quarter one year prior. This is a clear sign of strength within the company. In comparison to the other companies in the Oil, Gas & Consumable Fuels industry and the overall market, BUCKEYE PARTNERS LP's return on equity is significantly below that of the industry average and is below that of the S&P 500.
Buckeye Partners, L.P. owns and operates refined petroleum products pipeline systems in the United States. Its Pipelines and Terminals segment transports refined petroleum products and provides bulk storage and terminal throughput services in the continental United States. The company has a P/E ratio of 19.1, above the S&P 500 P/E ratio of 17.7. Buckeye Partners L.P has a market cap of $4.54 billion and is part of the basic materials sector and energy industry. Shares are down 22.8% year to date as of the close of trading on Tuesday.


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Try our new bite-sized pork pies topped with red and brown sauce
We love these new bite-sized pork pie treats topped with ketchup and brown sauce! We're the first major supermarket to stock them – give them a try and let us know what you think.
The mini pork pies topped with ketchup or brown sauce come in packs of four for £1.60 per pack. Also pictured are our chorizo pork pies which are £1.48 a pack.
They're part of our two for £2.50 deal on pork pies, sausage rolls, pasties, slices and picnic range.


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Tag Archives: eating clubs
December 15, 2009
Chabad, eating clubs give back for holidays
Student leaders listen to Rabbi Eitan Webb, right, at a celebration of the recent holiday food drive. At left is the "canorah," a menorah made of canned goods that will be donated to a food bank in Trenton. (Courtesy Francesca Furchtgott '12)
By Katy Pinke '10
Students walking to formal dinners at eating clubs Dec. 12 were struck by the vision of a giant menorah made out of canned goods, standing in the front lawn of Quadrangle Club. The structure was the product of "Giving Back at Formals," a holiday can drive that garnered participation from a wide range of student groups. The campaign was spearheaded by Princeton's Chabad House. The menorah, dubbed the "canorah" by event organizers, was built out of hundreds of cans purchased with money raised at the Frist Campus Center and donated by event sponsors.
The message of the event was both altruistic and spiritual. Yosef Razin '11 and Will Herlands '12 designed the "canorah," and student volunteers completed its construction on Thursday, a few days in advance of club formals, which fell on Hanukkah this year. To add to the holiday spirit, the Princeton University Band lined up around the menorah to play holiday music in the early afternoon on the day of formals. Cans and other donations will be driven to the food bank in Trenton this week.


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Enter your Email address:
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to maintaining your privacy and will not share your personal information without
your express consent. For more information, please refer to our Privacy Policy.
Dude, Annie MD, PhD; Neustadt, Amy MPH; Martins, Summer MPH; Gilliam, Melissa MD, MPH
Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, North Carolina; the Department of Psychiatry, University of Colorado Denver, Denver, Colorado; and the Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois.
Corresponding author: Annie M. Dude, MD, PhD, P.O. Box 3616, Durham, NC 27710; e-mail: firstname.lastname@example.com.
Presented at the 2009 Population Association of America Annual Meeting, April 29–May 1, 2009, Detroit, Michigan.
Financial Disclosure The authors did not report any potential conflicts of interest.
OBJECTIVE: To examine the prevalence of withdrawal (coitus interruptus) use among a cohort of U.S. females aged 15–24 years, to describe characteristics of withdrawal users, and to evaluate whether withdrawal users exhibit a higher risk of unintended pregnancy.
METHODS: We analyzed the 2006–2008 National Survey of Family Growth, estimating with a Cox proportional hazards model the risk of an unintended pregnancy over and up to a 47-month retrospective period among females aged 15–24 years who used withdrawal relative to females who used only other methods of contraception. We also examined correlates of withdrawal use using a logit model.
RESULTS: During the study period, 31.0% of females in our cohort used withdrawal. Of withdrawal users, 21.4% experienced an unintended pregnancy compared with 13.2% of females who used only other contraceptive methods (adjusted hazard ratio 1.75, 95% confidence interval [CI] 1.23–2.49). Withdrawal users were also 7.5% more likely to have used emergency contraception (adjusted odds ratio [OR] 1.57, 95% CI 1.13–2.20). Married females were 14.8% less likely than single females to use withdrawal (adjusted OR 0.58, 95% CI 0.35–0.96).
CONCLUSION: Use of withdrawal as contraception is common and might place females at higher risk of unintended pregnancy. Health care providers should be aware that many patients may use withdrawal, should consider the need for emergency contraception among these females, and should encourage them to use more effective methods of contraception.
In the United States, a majority of pregnancies (64–82%) among females aged 15–19 years and 20–24 years are unintended, a higher proportion than in other age groups.1 More than half of unintended pregnancies occur among females who were using contraception when they became pregnant.2 Females whose pregnancies are unintended are more likely to experience adverse pregnancy outcomes, including low-birth-weight neonates, preterm delivery, and preterm premature rupture of membranes.3–5
Coitus interruptus or withdrawal is a widely used but understudied contraceptive method. Most prior studies of this method have focused on older, married couples.6 Withdrawal use might be quite common, with between 10% and 60% of recent study cohorts reporting ever-use of withdrawal.7–13 Despite the high proportion of females who use withdrawal, most practitioners do not mention withdrawal when discussing contraception options with their patients.11 When withdrawal is used correctly every time a couple has sexual intercourse, the pregnancy rate is approximately 4% per year, a perfect use rate comparable to that of male condoms.14 However, the pregnancy rate, 18–28% per year of use, associated with typical use of withdrawal exceeds other methods.15,16
In this study, we examined whether withdrawal use and unintended pregnancy are correlated, as well as elucidated characteristics of females who choose withdrawal. Because withdrawal is typically less effective at preventing pregnancy than other methods, we hypothesized that withdrawal users will be more likely to report an unintended pregnancy. We focused on females aged 15–24 years because this age group is at highest risk of experiencing unintended pregnancy and accounts for an estimated 73% of unintended pregnancies in the United States.2,17
Our analysis used the first public release file of the continuous version of the National Survey of Family Growth, a nationally representative survey of U.S. females aged 15–44 years conducted from June 2006 to December 2008. The National Survey of Family Growth is a population-based survey drawing participants from the entire United States, which collects data on pregnancy incidence, pregnancy outcomes, contraceptive use, marriage, divorce, cohabitation, sexual behavior, economic status, and many other topics. Same-gender interviewers collected most of the data through in-person interviews. Interviewees self-administered a portion of the survey regarding sensitive information such as abortion history, using a computer to gain more accurate responses. The survey sampling design was based on geographic areas and oversampled for multiple subgroups, including African Americans and Hispanics, to render the sample truly representative. Complete information on survey design, implementation, coverage, refusal rates, and recoding can be found at: http://www.cdc.gov/nchs/NSFG.htm.
We used retrospective calendar data to construct our variable for contraceptive use. Starting with the January 3 years before the year of survey and continuing until the month before survey (up to 47 months), respondents were asked to choose from a preprinted list up to four contraceptive methods they had used in each month, including the option "withdrawal, pulling out." Respondents could change methods from month to month. We classified participants into two groups of contraceptive users: females who reported that they used withdrawal in at least 1 month ("withdrawal users") and females who used contraception in at least 1 month but did not report withdrawal as one of their methods in any month ("other contraception users").
For each pregnancy, participants reported the month of conception as well as their thoughts about the timing of the pregnancy. Unintended pregnancies included both those pregnancies that were unwanted (the woman did not want a child at the time of pregnancy or in the future) and those that were mistimed (the woman wanted a child in the future but not at the time she actually got pregnant). We categorized pregnancies about which participants indicated "indifferent" or "did not care" as well as pregnancies that were reported to occur "too late" rather than too early, as intended. We used these questions to construct our measure of unintended pregnancy rather than whether the pregnancy was terminated, both because abortions are underreported in the National Survey of Family Growth and because many unintended pregnancies are carried to term.18
We also included several control variables in our analyses that prior studies have indicated are associated with withdrawal use, unintended pregnancy, or both.1,19 Some National Survey of Family Growth variables are only measured at the time of survey, including educational attainment (ranging from 9 to 19 years), whether the woman was currently in the labor force, number of lifetime sex partners, whether she had been tested or treated for a sexually transmitted infection in the past 12 months, whether she had ever used emergency contraception, and whether she wanted more children in the future. Retrospective calendar data on births and relationship histories enabled us to measure some variables at the time of censoring rather than survey, including age, relationship status (married, cohabitating, or single noncohabitating), and total number of live births. Finally, some variables we included remained constant over time, including race and ethnicity (white non-Hispanic, African American non-Hispanic, Hispanic, and other) and age at first sex. In keeping with the approach of Ranjit et al,15 we measured economic status using a dichotomous variable indicating whether an individual reported that her household income was at or below 200% of the federal poverty line in the year before the survey.
We used calendar data on contraception and pregnancy for all months reported by sexually experienced females (defined as having had sex at least once since menarche) aged 15–24 years. Participants were right-censored (no longer contributed data to our study) at the month of their first pregnancy during the study period, at the month of tubal ligation, at the month in which they turned 25 years of age, or at the time of survey. We excluded participants who did not use contraception in any month, because these females are likely quite different from others in terms of their pregnancy intentions and sexual behaviors. We excluded participants who were missing any contraceptive information, those for whom the month and year of their tubal ligation were unknown, those who received a tubal ligation before the start of the study, and those who were pregnant at the start of the study. We also excluded participants missing data for at least one of the variables in our multivariable models.
We estimated either the proportion or the mean value of each variable to delineate descriptive statistics for our sample. We used bivariate analysis to compare proportions (for categorical variables) or mean values (for continuous variables) of key predictors in two mutually exclusive populations: females who had an unintended pregnancy and females who did not have an unintended pregnancy (which included females who had an intended pregnancy). We determined statistical significance of the association in the bivariate comparisons using χ2 tests for categorical variables and modified Wald tests for continuous variables.
We performed multivariable analysis using Cox proportional hazard models to estimate hazard ratios and 95% confidence intervals (CIs) for correlates of an unintended pregnancy. We used a multivariable logit model to estimate odds ratios (ORs) and 95% CI associated with predictors of withdrawal use during the study period. We included covariates in both multivariable models if they were associated with either unintended pregnancy or withdrawal use at P<.05 in bivariable comparisons.
We carried out all analyses in STATA 11.0; we considered associations statistically significant at the P<.05 level. We weighted all regressions using the "svy" series of commands in STATA as well as the included variables for probability sampling weights, strata, and principle sampling units to account for survey design effects given that the National Survey of Family Growth is a survey that uses a multistage sampling design and is not a simple random sample. Although accounting for survey design effects results in increased standard errors in our estimated models, we believe that because the geographic and demographic variables used to define the sampling frame are likely correlated with unintended pregnancy and withdrawal use, these survey effects must be accounted for to produce unbiased conclusions for this study.20
The research reported in this article was registered and deemed exempt from review by the University of Chicago Biological Sciences institutional review board.
The National Survey of Family Growth included 2,640 sexually active female respondents who were aged 15–24 years during at least some part of the study period. We excluded 88 nonusers of contraception, three females who were missing contraceptive information, 33 females for whom the month and year of their tubal ligation were unknown, 31 females who received a tubal ligation before the start of the study, and 211 females who were pregnant at the start of the study. Fifty-four participants were missing data on covariates examined in bivariate and multivariable analysis; χ2 tests indicated that these females were no more likely to experience an unintended pregnancy (P=.89) or differ in their use of withdrawal (P=.28) from those with complete data. These 54 participants were also excluded from our final study sample, which included 2,220 females who contributed a mean value of 22.4 calendar months of data.
Within our final study sample, 31.0% of females used withdrawal for at least 1 month during the study, and 69.0% relied solely on other methods of contraception (Table 1; we calculated all percentages using weights to account for survey design effects and thus those presented differ from raw percentages). Most withdrawal users (89.8%) also used other methods during the course of the study. Of the females who used withdrawal as their only form of contraception, 11.3% had an unintended pregnancy compared with 22.6% of those who used withdrawal among other contraceptive methods (P=.11). Almost all (56/62) of the females who relied solely on withdrawal during the study period had tried another contraceptive method at some point in their life.
During the study period, 665 females (26.6% of the weighted sample) experienced a pregnancy; 414 of these pregnancies (59.2% of the weighted sample) were unintended. Overall, 15.7% of females experienced an unintended pregnancy during the study period. Females who used withdrawal were at higher risk of an unintended pregnancy compared with females who solely used other forms of contraception (21.4% compared with 13.2%), even after controlling for other factors (adjusted hazard ratio 1.75, 95% CI 1.23–2.49; Table 2). Females tested or treated for a sexually transmitted infection in the year before their interview were more likely to experience an unintended pregnancy (24.1% compared with 12.2%) as were females living in poverty, African American females, and those in cohabitating relationships (as compared with noncohabiting singles). Parity, a desire to have more children, and years of education were inversely associated with reporting an unintended pregnancy (Table 2). Removing participants who reported intended pregnancies did not change our finding of increased risk of unintended pregnancy among females who use withdrawal (adjusted hazard ratio 1.78, 95% CI 1.24–2.55).
We compared characteristics of females who reported withdrawal use with those of females who used only other contraceptive methods (Table 3). Withdrawal users were 7.5% more likely to have used emergency contraception (adjusted OR 1.57, 95% CI 1.13–2.20). Married participants were 14.8% less likely than single respondents to report withdrawal use.
We demonstrated that withdrawal use is quite common among young U.S. females, because nearly one-third of females aged 15–24 years in our nationally representative sample indicated that they had recently used withdrawal. Females who used withdrawal were at a higher risk of unintended pregnancy compared with those who used other forms of contraception. The majority of pregnancies in this study were unintended. Withdrawal use in lieu of effective methods of contraception may contribute to high rates of unintended pregnancies among U.S. females.
Using withdrawal as contraception requires determination and communication by both the male and female partners21 and can be an effective method of contraception, particularly among long-term, monogamous couples committed to consistent use.6 Previous qualitative research indicates that young females typically use withdrawal as a substitute contraceptive method when they have forgotten to use a hormonal method, have difficulty using condoms, or as an "emergency" form of contraception for unanticipated intercourse, often during a female's very first sexual experience.11,12 Females in this age group who use withdrawal are also more likely to engage in other risk behaviors such as having multiple sex partners.22 These contextual factors as well as fertility status may reflect why withdrawal use is particularly ineffective for young females. In this study, females who solely used withdrawal were less likely to experience an unintended pregnancy, perhaps because they were more consistent in their use of this method, although this difference was not significant. Females in long-term marital or cohabitating relationships were less likely to choose withdrawal.
Most females in this study, however, did not use withdrawal as their only contraceptive method. Whittaker and colleagues23 indicated that many females who use withdrawal do so because they are dissatisfied with hormonal methods or condoms. These same authors noted that their study participants almost never discussed withdrawal with their reproductive health care provider. Given that almost all withdrawal users in our study also used more effective methods of contraception at some point, practitioners might build on their patients' desire to prevent pregnancy to support their use of more effective contraceptive methods. As Whittaker and colleagues23 also noted, most young females learned about withdrawal from sources such as peers, parents, and the media and often harbored misperceptions regarding the basic mechanism and efficacy of this practice.
The limitations of our study must be noted. First, it is likely that withdrawal users are heterogeneous. Our category of "withdrawal user" included females who used withdrawal in 1 month only as well as those who used withdrawal more regularly. Females in these two categories likely have different risks of unintended pregnancy. Nevertheless, we found that exclusive withdrawal users had a similar risk of unintended pregnancy when compared with females reporting use of withdrawal among other methods. Second, others have noted withdrawal use is underreported in the National Survey of Family Growth and other large surveys, in part because females may not consider withdrawal a contraceptive method.11 Underreporting of withdrawal among females in our "other contraception" category would cause us to overestimate the risk of an unintended pregnancy among withdrawal users. Although participants could only list up to four methods each month, only one to two females each month reported a fourth contraceptive method, indicating that any underreporting of withdrawal was likely not because respondents ran out of space. Third, surveys in general are subject to recall bias and these biases may be exaggerated for withdrawal. Although most females likely reported the dates of their pregnancies correctly, one would imagine recalling each contraceptive method is difficult and intermittent withdrawal use even more difficult. Fourth, we use calendar data, allowing us to know that contraceptive use preceded pregnancy. However, other covariates (eg, educational attainment, ever-use of emergency contraception, economic status) were measured at the time of survey and may not reflect conditions at the time of pregnancy or contraceptive choice. Finally, we likely included in our study some females who, for a portion of observation time, were not truly at risk of an unintended pregnancy as a result of changes in pregnancy intention, although removing participants who reported intended pregnancies during the study period did not change our main conclusion.
Despite these limitations, this study demonstrated a high prevalence of withdrawal use and an association with unintended pregnancy. Although unintended pregnancy and withdrawal can be difficult to classify, even intermittent use of withdrawal is associated with an increased risk of unintended pregnancy. Withdrawal users are more likely to use postcoital methods, an additional marker for risk of undesired pregnancy. Ultimately, withdrawal use is an important marker of pregnancy risk and even females who report contraceptive use may also use withdrawal. Furthermore, these females are at high risk of sexually transmitted infections. Our study suggests that clinicians should routinely inquire about withdrawal use even among females reporting condom and combined hormonal contraceptive use.
© 2013 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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Condo Act - ILSA CS/SB 120 CS/CS/HB 175
4-4-13 The fix for the interstate land sales act problem with current Florida condo law passed the Senate 40-0. The house companion bill HB 175, has passed all committees of reference and is awaiting floor action.
Amendments have been proposed to the Condominium act allowing for the early recording of a condo declaration to create legal descriptions during the presale process so that presales are not in violation of the Interstate Land Sales Act.
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Lebanon, NJ Hotels
Choose dates of your desired stay and Get Rates to display currently available nightly rates.*
Courtyard Lebanon
300 Corporate Drive
Lebanon, NJ 08833
Rates Recently Found: ($129.00 - $139.10)
3 Star
With a convenient location along I-78 and Route 22 NJ, Courtyard Lebanon offers easy access to Salem Industrial Park, Alba Vineyards and the Crayola Experience. Our centrally located hotel is also nea ... Click for More Info
New Jersey Offbeat Attraction Map
Quirky Tourist Attractions in or near New Jersey
While in New Jersey, you might enjoy a visit to:
Upper Black Eddy, Pennsylvania: Ringing Rocks Park
A four-acre pile in the middle of the woods, where boulders, when struck, emit a sound more musical than the typical rock thud. But Mom says I have to quit hitting everything with a hammer.
Plainsboro, New Jersey: Elsie the Cow Exhibit
Town museum chronicles the story of super-cow Elsie and the Walker-Gordon Farm where she lived.
Edison, New Jersey: World's Largest Light Bulb
It's perched atop an Art Deco tower, which stands where Thomas Edison once had a workshop. A small museum next door is packed with Edison inventions.
Edison, New Jersey: Light Dispelling Darkness - WPA Art
Science, Industry, and Education dispel War, Famine, Pestilence, Death, Greed, and Materialism. In a fountain. Elaborate and alarming.
© roadsideamerica.com, Doug Kirby, Ken Smith, Mike Wilkins. Information provided as an unofficial resource on attractions as a convenience to our visitors. Information and status -- location, hours open, admission prices, current exhibits, and other aspects -- are subject to change without our knowledge.
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Christmas tablature melodies for uke
The ukulele melodies on this page are popular Christmas carols and songs arranged for easy ukulele containing the melody notated with sheet music and corresponding tab notation below the staff.
Christmas ukulele at Sheet Music Plus
Free ukulele tablature sheet music (PDF)
- Angels We Have Heard On High - Ukulele tablature melody (video)
- Away In A Manger - utm (video)
- Christ Was Born On Christmas Day - utm (video)
- Deck The Halls - utm (video)
- Ding, Dong, Merrily On High - utm (video)
- Go, Tell It On The Mountain - utm (video)
- God Rest Ye Merry, Gentlemen - utm (video)
- Hark! The Herald Angels Sing - utm (video)
- Infant Holy, Infant Lowly - utm (video)
- Jingle Bells - Ukulele tablature melody (video)
- Jolly Old St. Nicholas - utm (video)
- Joy To The World - utm (video)
- O Come All Ye Faithful - utm (Adeste Fideles)
- O Christmas Tree - utm (O Tannenbaum) (video)
- O Holy Night - utm (video)
- Once In Royal David's City - utm (video)
- Silent Night - utm (video)
- The First Noel - utm (video)
- We Wish You A Merry Christmas - ukulele tablature melody (video)
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Ukulele Heroes - Five People Most Associated With the Ukulele
By Al Wood
Few instruments go in and out of fashion quite as regularly as the ukulele.
During the last 100 years, the ukulele has at times been more popular than
the guitar and at other times completely obscure. Whenever the instrument
seems dead and buried, someone comes along to revive interest in the instrument.
These five people are responsible for more people picking up the ukulele
than anyone else.
Cliff Edwards
Cliff Edwards was a huge Hollywood star. His career spanned from the 1920's to the 1960's. He is best known as the voice of Jiminy Cricket and for his Oscar winning performance of When You Wish Upon A Star. He is also known as 'Ukulele Ike' and was almost single-handedly responsible for creating the image of the ukulele crooner and also the trend for scat singing along with the ukulele.
He launched the first generation of ukulele players in the mainland US and published three books of ukulele songs.
George Formby
In the UK, the ukulele is almost synonymous with George Formby. Like Cliff Edwards, Formby was both a musician and film star. However, his image couldn't have been more different. He didn't have Edwards' looks and dark charisma, but he did have a huge amount of light-hearted charm. And it was this much needed light-heartedness that launched him to fame during the Second World War.
His fame was so great that he is still revered in the UK. The George Formby Society has being going for over 40 years and counted George Harrison amongst its membership.
Arthur Godfrey
By the late 1940's, the first boom of the ukulele was well and truly over. Very few ukuleles were being sold. This all changed when Arthur Godfrey began playing one on his radio and TV shows. He even briefly had a TV show giving ukulele lessons: Arthur Godfrey and his Ukulele.
He was a huge promoter of the instrument. After he started advertising them, sales of new plastic ukuleles made by Macaferri went through the roof. Also, he commissioned the building of the first baritone ukulele.
Israel Kamakawiwo'ole
Israel Kamakawiwo'ole (or IZ to give him his more easily spelled nickname) was a huge Hawaiian sensation. He is most famous for his ukulele based version of Somewhere Over the Rainbow in 1997. The clip was used in the film 50 First Dates, has become a YouTube sensation with over 10 million views and inspired Jason Castro's version on American Idol.
Jake Shimabukuro
Unlike the other people on this list, Jake Shimabukuro uses the ukulele as a solo instrument. He is the first person to take the idea of the ukulele as a lead instrument into the mainstream. Learning to play his solo arrangement of The Beatles' While My Guitar Gently Weeps is now a rite of passage for all aspiring ukulele players.
Al Wood writes about the ukulele and ukulele chords and has a guide to ukuleles for sale.