text:
A few years back a manuscript (for review purposes) came mailed to my house, not too long after I joined Patheos as the managing editor of the Muslim channel. It was Love, InshAllah - The Secret Love Lives of American Muslim Women. I was hooked. Some chapters spoke to me, some shocked me and made me really uncomfortable, while others made me reflect more on love in my own relationships. More than anything, it made me think of the conversations about love and relationships that I want to have … [Read more...]
Patheos Welcomes the "Love, InshAllah" blog
It's a Friday night, and I'm doing one of the things I love most to do – watching your little legs pump furiously up and down the field as you chase after the ball with your teammates, playing the kind of crazy, legs-a-flying soccer that only five- and six-year-olds can play. There is a cloud of legs and dust wherever the ball goes, and finally, after four seasons of playing, your "one shining moment" has come:You score!You run down the field and leap into my arms, pumping your fists and … [Read more...]
Usually you have the third row of the car all to yourself, but with your Nanajan (maternal grandfather) catching a ride with us, I'm sitting with you in the back, encroaching upon your space. But you don't seem to mind. You are unexpectedly happy to have the company.So this is the perspective from where you sit every time. It's bouncier back here, and though the people in the front – usually me and your Baba – are less than seven feet in front of you, somehow we seem far away, our voices muff … [Read more...]
You are Enduring Love
My darling boy,The sun is shining and the air is warm with the scents and sounds of a spring most awaited. You are swinging in the hammock in the backyard, spinning your beads on a twig with your hoodie pulled over your head and sunglasses perched on your face. God, you are handsome.It seems fitting that on today, World Autism Day 2014, we have come to a point in our autism journey where the path has played a cruel, cruel trick on us. Where there seems to be no alternate route, where the … [Read more...]
To Have and to Hold
Last night after putting you to bed, after turning off the bedroom light and turning the closet light on and leaving the door ajar, after turning on your white noise machine, after uttering my usual nighttime prayer for you, after rubbing coconut oil on the lingering scars on your face and your consistently chapped lips, after covering you with your favorite heavy blanket and kissing your forehead, I left the room and shut the door.Throughout all this you said nary a word to me. You giggled, … [Read more...]
Finding His Calm
What is the function of the behavior?I can't tell you how many times special education teachers, therapists and behavior therapy experts have asked me that regarding why Lil D does the things he does and the way he does them. Friends and family will ask a different version of this question – What's going on with him? Why does he do [fill in the blank]?I'm sitting with him in the basement watching him go through his current stages of retreat, which may or may not be accompanied by a full-o … [Read more...]
A Big Brother in Autism Land
When I glance up at the clock from my computer, I see that it's 5:30 p.m. Where does the time go? As many times as I've vowed to cook dinner earlier in the day so I'm not panicked to make Lil D's 6:30-7:00 p.m. dinner deadline, inevitably it comes down to the last hour.I click my laptop shut and move two feet into the kitchen and get to work. Lil D is out with his therapist on one of his CBI outings (community-based instructions), and I'm pretty sure Amal is in the dining room finishing her h … [Read more...]


text:
#1 Ranked Children's Hospital by U.S. News & World Report
MyPatients provides referring primary care providers with secure access to their patients' information.
Boston Children's has launched the world's 1st program dedicated to offering hand transplants to children who qualify.
Innovation insider is a semi-monthly e-newsletter analyzes innovations at Boston Children's, other academic medical centers and from industry.
Read the latest blog by a Boston Children's doctor, clinician or staff member.
There are many ways you can help children and their families get the care they need.
Boston Children's Hospital's Midaortic Syndrome and Renovascular Hypertension (MAS/RVH) Program diagnoses, treats and provides long-term care for pediatric patients with either or both of these rare disorders.
Not only are MAS and RVH rare and potentially life-threatening conditions; they can also affect different children in very different ways. It's essential to seek care from a team of pediatric specialists who are highly experienced in diagnosing and treating these conditions and all related complications.
Most children with midaortic syndrome and/or renovascular hypertension are diagnosed after being examined for signs of severe high blood pressure (hypertension).
The exact symptoms of MAS/RVH will depend on the individual child, but can include:
Some of the tests our doctors may use to confirm that a child has MAS and/or RVH are:
angiography—injection of a special dye into blood vessels, then using X-ray imaging to look for narrowing
ultrasonography—a painless, non-invasive procedure that uses special sound waves to create pictures of a child's organs
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
The treatment approach for each child depends very much on:
Treatment options typically include one or more of the following:
medication to control blood pressure and improve heart and/or kidney function
angioplasty—the use of a narrow tube called a catheter to insert and inflate a balloon inside the narrowed artery, widening it and improving blood flow to the affected organs
stenting—the placement of a special tube called a stent in a narrowed artery to hold it open
In the most serious cases, doctors may recommend:
bypass graft surgery—an operation that makes detours, or "bypasses," around narrowed arteries, creating new paths for blood to flow
autotransplantation—moving a kidney to a new location where the blood flow can be improved
kidney transplantation (in cases where both kidneys are damaged to the point of causing irreversible kidney failure)
In a very exciting development, Boston Children's Hospital has pioneered a novel way of "stretching" the healthy vessels in the aorta to make them long enough to adequately replace the narrowed vessels. This procedure is called Tissue Expander Stimulated Lengthening of Arteries (TESLA).
We are grateful to have been ranked #1 on U.S. News & World Report's list of the best children's hospitals in the nation for the third year in a row, an honor we could not have achieved without the patients and families who inspire us to do our very best for them. Thanks to you, Boston Children's is a place where we can write the greatest children's stories ever told."

subset: commoncrawl


text:
Joint Board for the Enrollment of Actuaries
From Wikipedia, the free encyclopedia
The Joint Board for the Enrollment of Actuaries licenses actuaries to perform a variety of actuarial tasks required of pension plans in the United States by the Employee Retirement Income Security Act of 1974 (ERISA). The Joint Board consists of five members – three appointed by the Secretary of the Treasury and two by the Secretary of Labor – as well as a sixth non-voting member representing the Pension Benefit Guaranty Corporation.
The Joint Board administers two examinations to prospective Enrolled Actuaries. After an individual passes the two exams and completes sufficient relevant professional experience, she or he becomes an Enrolled Actuary.


text:
The incidence of hypoxemia during surgery: evidence from two institutions
- First Online:
- Received:
- Accepted:
DOI: 10.1007/s12630-010-9366-5
- Cite this article as:
- Ehrenfeld, J.M., Funk, L.M., Van Schalkwyk, J. et al. Can J Anesth/J Can Anesth (2010) 57: 888. doi:10.1007/s12630-010-9366-5
- Citations
- 655 Downloads
The incidence of hypoxemia in patients undergoing surgery is largely unknown and may have a clinical impact. The objective of this study was to determine the incidence of intraoperative hypoxemia in a large surgical population.
We performed a retrospective study of electronically recorded pulse oximetry data obtained from two large academic medical centres. All adults (age ≥ 16 yr) undergoing non-cardiac surgery during a three-year period at the two hospitals were included in the analysis. Our main outcome measure was the percentage of patients with episodes of hypoxemia (SpO2 < 90) or severe hypoxemia (SpO2 ≤ 85) for two minutes or longer during the intraoperative period (induction of anesthesia, surgery, and emergence).
We evaluated 95,407 electronic anesthesia records at the two hospitals. During the intraoperative period, 6.8% of patients had a hypoxemic event, and 3.5% of patients had a severely hypoxemic event of two consecutive minutes or longer. Seventy percent of the hypoxemic episodes occurred during either induction or emergence— time periods that represent 21% of the total intraoperative time. From induction to emergence, one episode of hypoxemia occurred every 28.9 hr, and one episode of severe hypoxemia occurred every 55.7 hr of intraoperative time.
Despite advances in monitoring technology, hypoxemia continues to occur commonly in the operating room and may be a serious safety concern because of its potential impact on end organ function and long-term outcomes. Further studies are needed to improve our understanding of the clinical impact of intraoperative hypoxemia and the strategies that will be most useful in minimizing its occurrence.
Incidence de l'hypoxémie pendant la chirurgie: données probantes de deux institutions
L'incidence de l'hypoxémie chez les patients subissant une chirurgie est très mal connue et pourrait avoir des répercussions cliniques. L'objectif de cette étude était de déterminer l'incidence de l'hypoxémie peropératoire chez une vaste population chirurgicale.
Nous avons réalisé une étude rétrospective des données d'oxymétrie du pouls sauvegardées électroniquement dans deux centres médicaux universitaires importants. Dans notre analyse, nous avons inclus tous les adultes (âge ≥ 16 ans) subissant une chirurgie non cardiaque au cours d'une période de trois ans dans les deux hôpitaux. La mesure principale était le pourcentage de patients manifestant des épisodes d'hypoxémie (SpO2 < 90) ou d'hypoxémie sévère (SpO2 ≤ 85) pendant deux minutes ou plus en période peropératoire (induction de l'anesthésie, chirurgie et réveil).
Au total, nous avons évalué 95 407 dossiers anesthésiques électroniques dans les deux hôpitaux. En période peropératoire, 6,8 % des patients ont subi un événement hypoxémique, et 3,5 % des patients ont subi un événement hypoxémique grave de deux minutes consécutives ou plus en période peropératoire. Soixante-dix pour cent des épisodes hypoxémiques sont survenus pendant l'induction ou le réveil, des périodes représentant 21 % du temps peropératoire total. De l'induction au réveil, un épisode d'hypoxémie est survenu toutes les 28,9 heures de temps peropératoire, et un épisode d'hypoxémie grave est survenu toutes les 55,7 heures.
Malgré les progrès réalisés au niveau des technologies de monitorage, l'hypoxémie continue d'être un événement fréquent en salle d'opération et pourrait constituer une problème de sécurité sérieux en raison de ses répercussions potentielles sur la fonction des organes cibles et les devenirs à long terme. D'autres études sont de mise pour améliorer notre compréhension des répercussions cliniques de l'hypoxémie peropératoire et des stratégies qui seront le plus utiles pour minimiser sa survenue.
Hypoxemia is recognized as one of the most serious risks patients face during anesthesia and surgical care. Pulse oximetry has become an essential component of operating room technology to detect, treat, and reduce the degree of intraoperative hypoxemia in the developed world.1 Pulse oximetry has been endorsed by the Canadian Anesthesiologists' Society, American Society of Anesthesiologists (ASA), World Federation of Societies of Anaesthesiologists, and the World Health Organization as a minimal monitoring standard during surgery.2-5 Before the widespread adoption of pulse oximetry in the 1980s and the establishment of anesthesia monitoring standards in the 1990s, hypoxemia was the leading cause of anesthesia-related mortality.6,7 Since then, anesthesia-related mortality has dropped nearly 20-fold in developed settings.8-10 Much of this decline is attributable to improvements in the safety of anesthesia administration and monitoring, including the nearly universal use of pulse oximetry that has been associated with the earlier diagnosis and correction of hypoxemia.7,11-14
With the decline in anesthesia-related mortality, we have focused our attention on understanding the long-term effects of exposure to anesthesia.15 One area of great uncertainty is the clinical impact of transient hypoxemia during surgery. To date, no published studies using current-generation pulse oximetry technology have characterized the incidence or severity of hypoxemia during surgery. Additionally, the clinical impact of transient intraoperative hypoxemia on outcomes such as surgical site infections, postoperative cognitive dysfunction, and other end organ dysfunction, such as myocardial and renal insufficiency, has not been studied.
The recent advent of electronic anesthesia record keeping systems16-18 that automatically record intraoperative physiologic parameters has made it possible, for the first time, to examine pulse oximetry data from a large number of surgical patients during routine care. Therefore, the aim of this retrospective study was to utilize electronic intraoperative records to determine the incidence, severity, and duration of hypoxemia in a large population of surgical patients at two major academic medical centres.
Following approval of the study protocol by the Institutional Review Boards of two large academic tertiary hospitals— both with active transplant programs and surgical volumes in excess of 40,000 cases annually—electronically recorded pulse oximetry data were obtained from the anesthesia information management systems at both centres utilizing a structured query language. Data were collected over a three-year period (Hospital A: April 2006 to April 2009; Hospital B: November 2005 to January 2009) for each patient who underwent general anesthesia and for whom a completed electronic anesthesia record was available.
For each patient, the database query returned all pulse oximetry values, patient demographics (age, sex, American Society of Anesthesiologists' [ASA] physical status classification), surgical procedure, and case duration. Pediatric patients (age < 16 yr), patients undergoing cardiopulmonary bypass, and procedures performed outside of the operating room (e.g., magnetic resonance imaging, endoscopy, radiology) were excluded from the study. Case milestones (induction of anesthesia, start of surgery, end of surgery, patient departure from the operating room) were also obtained from the electronic anesthesia databases in order to separate pulse oximetry signals into discrete case phases.
Current generation pulse oximeters (Hospital A: Radical 7 - Masimo, Irvine, CA, USA; Hospital B: Nellcor - Boulder, CO, USA) utilizing conventional red and infrared photoplethysmography, digital signal processing, and adaptive filtration were used during the study period. The pulse oximeters were configured to provide either an eight-second (Hospital A) or 20-sec (Hospital B) average of oxygenation (SpO2) values. This information was polled by the information management systems either every 60 sec (Hospital A) or every 30 sec (Hospital B). All values recorded by the information management systems were included in the analysis.
We calculated the number and duration of episodes of both hypoxemia (SpO2 < 90) and severe hypoxemia (SpO2 ≤ 85) for each patient. We chose these definitions on the basis of the accepted definition of hypoxemia (SpO2 < 90 that correlates with a PaO2 of < 60 mmHg) and previous studies that have defined severe hypoxemia as SpO2 ≤ 85.12,19,20 Episodes of hypoxemia and severe hypoxemia were then categorized according to maximum duration per patient and according to the phase of intraoperative care during which they occurred: induction of anesthesia to start of surgery (induction), start of surgery to end of surgery (surgery), or end of surgery to departure from the operating room (emergence).
When calculating episode durations, we categorized hypoxemic events as lasting one, two, three, four, five, or ≥ six minutes. We treated each individual value recorded in the anesthesia information management systems as persisting until replaced by a new value. Thus, at Hospital A, two consecutive abnormal values sampled every 60 sec represented a two-minute hypoxemic episode. Three consecutive abnormal readings represented a three-minute hypoxemic event. At Hospital B, four consecutive abnormal values sampled every 30 sec represented a two-minute hypoxemic episode, while six consecutive abnormal values represented a three-minute hypoxemic event. In order to allow comparison of data between Hospital A and Hospital B, episodes at Hospital B that consisted of an odd number of values were divided evenly into adjacent bins (e.g., the group of patients with three consecutive abnormal values representing 1.5 min was split evenly into either the one-minute bin or the two-minute bin). In order to understand the effect of our treatment of the odd number of consecutive readings at Hospital B, a sensitivity analysis was performed by modelling the effects of downscaling data recorded at 30-sec intervals into data recorded at one-minute intervals using a Weibull distribution.
For each episode of hypoxemia and severe hypoxemia that lasted two minutes or longer, we then calculated the average number of hours between instances. Our goal was to report how often providers encounter hypoxemia in routine practice. We performed this calculation only on episodes that lasted two minutes or longer, because we wished to increase our specificity for detecting episodes that were truly reflective of hypoxemia by including episodes where multiple abnormal SpO2 recordings occurred sequentially—and excluding non-consecutive readings that might be more reflective of artefact.
Mean age, sex, ASA physical status classification, number of emergency cases, and average surgical times for the entire sample were also calculated. To validate the accuracy of the electronic data query, a random sample of print-outs of anesthesia information management system records from 100 patients at each hospital was manually compared with the information returned from the data query.
Patient demographics
Hospital A
Hospital B
(n = 55,775)
(n = 39,632)
Mean age (yr)
(standard error)
53.4 (0.07)
48.3 (0.10)
Sex (%)
ASA physical status (%)
5 & 6
Emergency cases (%)
Surgical time (min).
Mean (standard error)
107 (0.4)
73 (0.4)
Incidence and timing of hypoxemia
Hospital A and B (n = 95,407)
Induction of anesthesia to start of surgery
Start of surgery to end of surgery
End of surgery to exit OR
Mean duration of each interval
12 min
93 min
12 min
Patients with hypoxemia (SpO2 < 90) n (%)
7,101 (7.4%)
6,908 (7.2%)
8,875 (9.3%)
Patients with severe hypoxemia (SpO2 ≤ 85) n (%)
3,954 (4.1%)
3,582 (3.8%)
5,157 (5.4%)
Summary of findings
Our data revealed that 6.8% of patients were hypoxemic and 3.5% were severely hypoxemic for two consecutive minutes or longer during the intraoperative period. Among the SpO2 readings reflective of hypoxemia, episodes appeared to be relatively evenly divided among the three phases of intraoperative care, even though the induction phase (average time 12 min) and emergence phase (average time 12 min) were significantly shorter than the surgical phase (average time 93 min). From induction to emergence, an anesthesia provider in a tertiary care centre can expect to manage a period of hypoxemia of two-minute duration or longer at least once every 29 hr of intraoperative time.
Comparison with previous reports
Our findings are consistent with previous studies12,21-23 that have suggested that intraoperative hypoxemia occurs at a significant rate. The largest randomized evaluation of pulse oximetry23 revealed a combined incidence of hypoxemia in the operating room and postanesthesia care unit of 7.9% (n = 10,312), although it did not define the duration of hypoxemic episodes and used first generation pulse oximetry technology that is subject to additional signal artefact (Nellcor N-200, Ohmeda 3700 & Radiometer OXI). It appears that our results are generalizable, given the similarity between our results and this previous work, the large number of patients included in our study, and the similarity of results between our two centres (see Appendix).
The finding that 70% of hypoxemia occurs during only one-fifth of the time spent in the operating room is consistent with our clinical experience, which suggests that the time close to induction of anesthesia and emergence are particularly high-risk periods for hypoxemia. This intuition is supported by data from the ASA Closed Claims database, which has shown that difficult airway claims continue to comprise the highest percentage of claims.24 The majority of these claims are related to incidents that occurred during induction (67%), with similar numbers occurring during surgery (15%) and extubation (12%).25
Our data suggest that a surprisingly high percentage of patients experience sustained hypoxemia during surgery. Even in highly advanced surgical settings, approximately one in 15 patients experienced hypoxemia for at least two consecutive minutes, and one in 64 patients experienced hypoxemia for at least five consecutive minutes. These frequencies are likely higher in resource-limited settings throughout the world where pulse oximetry is often unavailable, and hypoxemia may not be recognized by the perioperative team. Given that approximately 234 million surgical procedures are performed annually worldwide,26 our report suggests that at least three million patients each year experience prolonged (≥ five minutes) and potentially preventable hypoxemia during surgery.
The thresholds for the duration and severity of hypoxemia that are likely to affect clinical outcomes are unknown, but the levels of hypoxemia reported in this study may have a clinical impact. Although the effect of oxygen saturation levels on surgical patient morbidity has been studied in several clinical trials, little has been published on the impact of transient hypoxemic events on surgical outcomes. Reduced cerebral oxygen saturation levels have been correlated with higher postoperative complication rates in thoracic surgery.27 Perioperative administration of supplemental oxygen has been shown to reduce the incidence of surgical-wound infections,28,29 to improve immune function,30 and to decrease the incidence of postoperative nausea and vomiting.31 Furthermore, hypoxemia has been demonstrated in a variety of animal models to have detrimental effects on almost every end organ.32 At the cellular level, hypoxia has been shown to lead to acute heart failure,33 pulmonary hypertension,34 and acute renal failure.35 Hypoxia-induced changes in neural tissue have been associated with decreased cognitive function.36 Additionally, numerous studies have demonstrated that even modest fluctuations in oxygen delivery may lead to cognitive dysfunction.37 One study has linked intraoperative desaturation (measured by cerebral oxygen monitoring) with a decline in postoperative cognitive function (POCD).38 In that study, patients who experienced a drop in cerebral oxygen levels of ≥ 25% were found to have a statistically significant decline in their Mini Mental State Examination scores measured seven days after surgery. Although the predictors of POCD are still not well understood, further examination of the impact of transient hypoxemia on POCD is warranted, because 5-12% of patients demonstrate POCD at three-month follow-up visits.39
The evidence base for the use of pulse oximetry has been questioned in previous studies.40 However, even the largest prospective randomized controlled trial of pulse oximetry23,41 was insufficiently powered to reveal a mortality benefit from pulse oximetry (nearly two million patients would have been required). Furthermore, a post-hoc analysis of this trial41 suggests that the use of pulse oximetry was associated with several key benefits, including a reduction in myocardial ischemia (from 0.2 to 0.1%; P = 0.03) and cardiac arrest (from 0.1 to 0.04%; P = 0.06). Endobronchial intubation and hypoventilation were also recognized more frequently.42
These clinical data and animal model studies suggest only that the hypoxemia we observed during surgery may have been clinically relevant. They do not establish a direct link between perioperative hypoxemia and poor clinical outcomes. However, as the oxygen-hemoglobin dissociation curve indicates, there is little reserve when saturations fall to < 90%, let alone 85%; undoubtedly, there is a threshold below which hypoxemia causes survivable end organ damage. The potential public health impact of our findings is difficult to quantify, but given the very large numbers of patients undergoing surgery with anesthesia globally, it may well be substantial.
Our data were derived objectively from routine clinical practice at two geographically distinct centres and demonstrate real-world validity by eliminating the biases often associated with study observation. However, the retrospective nature of our study does limit the conclusions we can draw. Specifically, our data do not provide information on the etiology of the episodes of hypoxemia, and we also lack data on patient outcomes.
Pulse oximeters have well-known technical limitations and various sources of artefact that may have influenced the quality of our data.43 Sensor malposition can lead to apparent hypoxemia; the incidence of this is unknown, but such artefacts are thought to be rare.44 Poor peripheral perfusion, hypothermia, hypotension, and advanced age have been shown to yield low-quality pulse oximetry readings.45
Since our study was a retrospective analysis of current practice, we were unable to compare our electronically recorded data with actual plethysmographic signals or to estimate the specific performance characteristics of the devices used in the study. However, pulse oximeters have been validated previously in multiple clinical trials,46-49 including several within the perioperative environment.50-52 These studies have shown that current generation pulse oximeters provide reliable readings when compared with arterial blood gas sampling – even in the circumstances with poor peripheral perfusion, hypothermia, and motion.50,51,53 All of the pulse oximeters used in the study adhere to the International Organization for Standardization (ISO) standards for pulse oximetry accuracy.54
We attempted to minimize the impact of spurious readings on our results in two ways. First, we validated our hypoxemia data on 200 randomly selected patients. The concordance between the data returned by the electronic query and the patients' anesthesia records was 100%, providing considerable reassurance in relation to our algorithms. Second, we focused on the percentage of patients who experienced episodes of hypoxemia that lasted two minutes or longer. We chose this interval because it ensured that each hypoxemic episode represented at least two consecutive abnormal readings - as opposed to single isolated values. While there is no standardized definition of what constitutes a hypoxemic episode under anesthesia, we believe that the selection of this interval strikes an appropriate balance between capturing events that are likely to be reflective of true hypoxemia and eliminating isolated spurious values. Additionally, in our practice, we consider any episode of hypoxemia that lasts at least two minutes to be clinically significant.
Since our data were recorded every 30 or 60 sec rather than continuously, they could have been subject to an undersampling artefact because a single value was used to summarize a series of values over a discrete time interval.55,56 Thus, undersampling may have underestimated the true frequency of hypoxemic episodes. However, since our sampling intervals were either 30 or 60 sec, such episodes would be sub-minute episodes of uncertain clinical significance. On the other hand, we treated each single value as being representative of the entire time interval over which it was recorded. This may have either over- or underestimated the duration of any given hypoxemic episode. Despite this possibility, we believe our methodology represents a logical compromise between these two competing concepts and aligns with the interpretation of these data points in clinical practice.
Finally, although pulse oximetry data were collected automatically by electronic systems without user intervention, the case milestones (i.e., induction of anesthesia, start of surgery, end of surgery, and departure from operating room) were manually entered events and, as such, may be subject to errors in data entry, for example, event latency.57 Furthermore, there is no universal definition for these events, although attempts have been made at standardization of anesthesia procedural times.58 While a discrepancy in case times might lead to the misclassification of the case phase for a particular hypoxemic episode, it would not affect the overall SpO2 data.
Anesthesia providers strive to avoid hypoxemia because of the risk of irreversible damage to the myocardium, brain, and other end organs. Despite these efforts, hypoxemia continues to occur in the operating room at a surprisingly high rate. This may represent a serious safety concern because of its potential impact on end organ function and long-term outcomes. Our findings suggest that a typical anesthesia provider is likely to encounter at least one episode of sustained (≥ two minutes) hypoxemia every 29 hr of intraoperative time. In the developing world where pulse oximetry is not universally available, hypoxemic episodes may well be more frequent and longer. Future studies that focus on whether these episodes are preventable and have a clinical impact are warranted.
Author contributions: Dr. Ehrenfeld had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Ehrenfeld, Gawande, Funk.
Acquisition of data: Ehrenfeld, van Schalkwyk.
Analysis and interpretation of data: Ehrenfeld, Funk, Gawande, Sandberg, Merry, van Schalkwyk.
Drafting of the manuscript: Ehrenfeld, Funk.
Critical revision of the manuscript for important intellectual content: Sandberg, Merry, Gawande, van Schalkwyk.
Financial support for the preparation of this manuscript was provided from department funds of the Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital and from 5T32GM007592 from the National Institute of Health.
Conflicts of interest
Dr. Merry has a financial interest in Safer Sleep LLC, a manufacturer of anesthesia information management systems.


text:
Authorities said on Sunday that a man suspected of killing three people and setting fire to a home in southern Colorado had been captured in Oklahoma after a nationwide manhunt.
Sheriff Kirk Taylor of Pueblo County, Colorado, said 59-year-old Harry Carl Mapps was captured at a motel in Roland, Oklahoma on Saturday night. No other details were released.
Mapps was wanted on charges of fatally shooting 55-year-old Kim Tuttle, her 51-year-old husband, Reggie Tuttle and their 33-year-old daughter, Dawn Roderick. Their bodies were found in the Tuttles' home in Rye after the house burned down on 27 November. The fire was ruled arson.
The US Marshals Service issued a fugitive warrant for Mapps and said authorities were searching for him around the country.


text:
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and many other similarities identified in the Music Genome Project
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|Message view
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|Jimmy Mehta <jme...@translations.com>
|Re: LOG4J - Different priority messages to different files
|Thu, 01 Nov 2007 19:01:05 GMT
Hey James , Thanks for you reply now i find another way that , i have three classes Job , Address , User. Now i want to put All messages of Job class into separate file and all Address messages to another file and same as in User. So if i set priority level in Job class like warn so all fatal , error and warn messages of Job class goes to one file and no any other class messages so how can i do it with Properties file?? Can you give me one sample code example so i can understand more clearly.. Appreciate ur help Jimmy Mehta James A. N. Stauffer wrote: > > I find that I want one file for each level and higher. i.e. Warn.log has > warn, error, and fatal messages. That can easily be done by setting > thresholds on each appender. If you want only a certain level then you > can > use a level match filter but that requires XML config. > > On 10/31/07, Jimmy Mehta <email@example.com> wrote: >> >> >> Hi, >> >> I am new to the LOG4J and i am trying to learn so i have a question that >> if >> i need to put different priority log messages to different log files. >> Suppose i want to put all warn messages to one file and all info messages >> to >> another file and all error messages to another file. My root priority is >> Info and I also set different packages to different priority level. >> >> Suppose com.tc.portal.xyz = info so how should i put different priority >> messages to different file >> >> Main thing , i want to make only change in log4j.properties file , i >> don't >> want to change java files >> >> Jimmy >> -- >> View this message in context: >> http://www.nabble.com/LOG4J---Different-priority-messages-to-different-files-tf4728211.html#a13519537 >> Sent from the Log4j - Users mailing list archive at Nabble.com. >> >> >> --------------------------------------------------------------------- >> To unsubscribe, e-mail: firstname.lastname@example.com >> For additional commands, e-mail: email@example.com >> >> > > > -- > James A. N. Stauffer http://www.geocities.com/stauffer_james/ > Are you good? Take the test at http://www.livingwaters.com/good/ > > -- View this message in context: http://www.nabble.com/LOG4J---Different-priority-messages-to-different-files-tf4728211.html#a13535224 Sent from the Log4j - Users mailing list archive at Nabble.com. --------------------------------------------------------------------- To unsubscribe, e-mail: firstname.lastname@example.com For additional commands, e-mail: firstname.lastname@example.com
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text:
Carnival Fascination
Carnival Fascination
|Carnival Corporation & plc
|Carnival Cruise Lines
|Port of registry:
|Yard number:
|Sponsored by:
|Jeanne Farcus
|In service:
|In service
|General characteristics
|Class and type:
|Fantasy-class cruise ship
|855 ft (261 m)
|103 ft (31 m)
|7.80 m (25 ft 7 in)
|Installed power:
|Two propellers, 3 bow thrusters, 3 aft thrusters,
|21 knots (39 km/h; 24 mph)
Carnival Fascination (formerly Fascination) is the fourth of eight Fantasy-class cruise ships operated by Carnival Cruise Line. Built by Kværner Masa-Yards at its Helsinki New Shipyard in Helsinki, Finland, she was floated out on July 1, 1994, and christened Fascination by Jeanne Farcus.[2]
During 2007, in common with all of her Fantasy-class sisters, she had the prefix Carnival added to her name.[3] She is currently home-ported in San Juan, Puerto Rico year-round sails to the Caribbean year-round.
The Fascination was given a multimillion-dollar refurbishment while in dry dock during September 2006,[4] during which all 1,026 staterooms and suites were completely renovated with the addition of flat-screen TVs, new furnishings, and refurbished bathrooms, the Coconut Grove Bar and Grill received new carpeting and upholstery, as did the Passage to India Lounge. The Imagination and Sensation Dining Rooms received new carpeting, upholstery, and sound systems and the Grand Atrium Bar was added on the Empress Deck. Bogart's Cafe, a new coffee bar, was added to the Promenade Deck.
A new 9-hole miniature golf course opened on the Sun Deck, the 1,600-square-foot (150 m2) Children's World, a new Camp Carnival facility, was added to the Verandah Deck and Club O2, a club exclusively for teens, was added.
An art gallery opened on the Empress Deck allowing passengers to view artwork available at auctions held on board, and a new photo gallery on the Promenade Deck allows passengers to view photos taken by staff on board. The 12,000-square-foot (1,100 m2) Spa Carnival was renovated with new exercise equipment and private treating rooms added while the whirlpool spas were removed; whirlpools are still available at the main pool area on the Lido Deck and the aft pool area on the Verandah Deck. The bandstand in the main pool area on the Lido Deck received audio-visual upgrades and the Palace Lounge received two new shows ("Hey Mambo" and "Far from Over: the 80s") to accompany a new revolving stage, orchestra area, stage lighting, and audio-visual equipment,[5] in addition Puttin' on the Ritz received new décor
In January 2010 Carnival Fascination underwent an additional dry dock and received the "Evolutions of Fun" upgrade. This included Carnival Waterworks, Serenity Adult only area, the addition of new balcony suites, and more.[6]
In January 2013, Carnival Fascination underwent another dry dock. Carnival Staff say that during this dry dock, all 1,026 staterooms will be renovated with new bedding and lighting. Three new restaurants will be added which include an American, Asian, and Southwestern style cuisine and the main dining room will be updated with new carpet and decor. The Carnival Fascination is not scheduled to receive the "full swing" of the lines FunShip 2.0 initiative. However, according to Carnival's brand ambassador and senior cruise director John Heald, the ship will receive both the RedFrog Rum Bar and the BlueIguana Tequila Bar, as well as Playlist Productions (the new LED screened shows in the main theater).
The Carnival Fascination currently departs from Jacksonville, replacing the Celebration which retired from Carnival[when?]. She offers 4-day cruises to the Bahamas, featuring stops in Nassau and Freeport and 5-day cruises including stops in Key West and Nassau on the Monday sailing. The alternate 5-day sailing (Saturday departure) stops at Nassau and Half Moon Cay.[7] In April and May, 2011, Fascination operated a 7 night itinerary stopping in Nassau, Half Moon Cay, and Grand Turk. Carnival later announced that all 7-Day sailings would be canceled, citing strong demand for the shorter 4 and 5 day sailings.[7]
The Fascination was the first Carnival ship to sail from New York. When she arrived in New York starting on July 24, 1994 - September 4, 1994 she sailed 5-Day cruises to Saint John, New Brunswick & Halifax, Nova Scotia. She also sailed 2-day cruises to nowhere, with the ship itself as the destination. After September she moved to San Juan, Puerto Rico.[8]
In 2013 and 2014, Coco Cay will replace Key West on some of the Carnival Fascination's itineraries. Coco Cay is a private island in the Bahamas owned by rival cruise line Royal Caribbean International.[9]
In April, 2016, Fascination repositioned to San Juan, Puerto Rico, where she now sails seven-day southern Caribbean cruises.[10]
Power Loss[edit]
In June 2010, the Carnival Fascination lost engine power due to a technical malfunction while returning to Jacksonville, Florida. Power was restored after several hours, and the ship was able to return to Jacksonville under its own power.[11]
Health Inspection Failure[edit]
In April 2013, it was reported that on February 21, 2013 the Carnival Fascination failed a CDC health inspection after inspectors found insects in food preparation areas, dried food waste, insufficient chlorination in the pools, and insufficient sneeze guards at the salad bars. A satisfactory rating from the CDC is a score of 85 or higher. The Fascination scored an 84. Carnival is not the only cruise line to get an "unsatisfactory" rating from the CDC in 2013 on one of its ships. Celebrity's Century and Summit also received unsatisfactory grades in 2013, scoring a 78 and 81, respectively. This incident marks a first in quite some time for Carnival. The cruise line said that in the past five years no carnival ship had failed an inspection. The fleet's average score during that time period was 97, Carnival said, and its average score over 20 inspections conducted in 2013 was 97.2. The same month Carnival Fascination failed its inspection, the Carnival Sensation scored a 100.[12]
- ^ Smith 2010, p. 37.
- ^ Dake, Shawn J. (January 2008). "Cruise Ships 2007 the year in review" (PDF). Ocean Times. Steamship Historical Society of America: Southern California Chapter. 12.1: 2–8.
- ^ Carnival Cruise Lines - News Release
- ^ Carnival Cruise Lines - News Release
- ^ "Carnival Fascination Returns to Service from Jacksonville Following Extensive "Evolutions of Fun"™ Upgrades". 2 February 2010. Retrieved 13 February 2012.
- ^ a b Sloan, Gene (1 August 2011). "Carnival adds more four- and five-day cruises out of Jacksonville, Fla". USA Today.
- ^ "Fun Ship From Fun City". Cruise Travel: 31. March–April 1994.
- ^ Sloan, Gene (27 February 2013). "New port for Carnival ships is owned by Royal Caribbean". USA Today. Retrieved 11 April 2013.
- ^ "Carnival Cruise Lines News". Carnival Cruise Lines News.
- ^ Carter, Adam. "5 troubles on Carnival cruises". CBC News. CBC. Retrieved 11 April 2013.
- ^ Golden, Fran (11 April 2013). "Carnival ship fails health inspection". USA Today. Retrieved 11 April 2013.
- Smith, Peter C. (2010). Cruise Ships: The World's Most Luxurious Vessels. Barnsley, South Yorkshire, UK: Pen & Sword Maritime. ISBN 9781848842182.
External links[edit]
- Media related to Carnival Fascination at Wikimedia Commons
- Official website


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Posted Wed 01 Jul 15 at 02:59 AM
United host home game at Ewood Park ...
The latest leg of the 'home' roadshow took Carlisle United to Ewood Park as repairs to the flood damage in Cumbria continue into the New Year.
A cross from wide from Mellor and a volley on the turn from Asamoah signalled early intent from both sides, and United went close again when Grainger twice had crosses blocked. Gilliead swopped on the loose pieces but his 20-yard drive smashed into the side netting.
Defender Mark Ellis then caused problems with two huge long throws, the second of which brought a corner as Raynes flicked it into the mix. Asamoah and Wyke were close to a touch as Grainger drilled that set piece into the six-yard box.
A foul on Jervis by Joyce gave Plymouth a chance to test the target and Gillespie had to go full length to stop a dipping shot which bent over the wall.
Jervis made space for himself when he got forward in support of Brunt as Plymouth took a direct route in their next attack, but his connection was weak and Gillespie was able to watch it all the way.
A wild shot from Wylde sailed high over the bar as the Pilgrims started to see more of the ball, but the visitors took the lead in bizarre circumstances when they were awarded a free kick 28 yards from goal for what appeared to be minimal contact as Jason Kennedy hustled for the ball. Ryan Brunt took it and a wicked deflection left the keeper with no chance as it rattled into his top corner.
Quick thinking from Sweeney almost put Asamaoh clean through as Carlisle looked for a response, but McHugh stayed big to close the route. And McHugh was the man on the spot again as another Sweeney cross bent into the area. His touch prevented Asamoah from finding any kind of finish.
Plymouth lived life on the edge as United kept the ball alive inside the box ahead of the break and McCormick was relieved when a heavy touch from Asamoah allowed him to drop low and gather it up.
Wyke had a shot on the run blocked as he looked to catch the keeper off guard, but there was plenty for the home side to feel positive about as they headed down the tunnel and into the half time team talk.
Gilliead and Grainger went for a training ground corner routine with just seconds on the second half clock but McHugh earned more praise when he bent low to stop Ellis from heading it in. And McCormick had to be on his toes as a precise pass picked Sweeney out just ten yards from the target. His acrobatic volley was gratefully scooped up as it flew right at the alert keeper.
An excellent block from Ellis stopped a fierce rocket from Brunt from doing any damage, and the big defender went close to grabbing one at the other end as he stayed forward for a free kick. The ball fell to him unexpectedly on the edge of the box and he was frustrated as his volley arrowed into the keeper's midriff.
Striker Charlie Wyke dragged a difficult chance across the face of goal as United kept the pressure on, and the Ellis long throw avenue almost paid off as Raynes, Joyce and Wyke kept it alive. Asamoah couldn't quite make up the ground as the ball bounced behind for a goal kick.
Patient football brought a half chance for Asamoah as passes from Ellis, Dicker, Joyce and Grainger took Carlisle deep. McCormick had to watch closely as a miscued header threatened to drop under his bar.
A quick Plymouth break followed and Brunt fed Wylde on an overlap with Carlisle light at the back. Gillespie closed the angles and saved confidently at his near post.
The impressive Mark Ellis, playing the last game of his current loan spell, was a whisker away as he timed a great run for a Grainger corner. His header had power but it whistled just the wrong side of the upright.
United pushed men forward, leaving themselves open to the counter, and Brunt won a corner when he carried the ball from deep. That came to nothing, but a second break from the same player led to a volley which whipped well wide under pressure.
The Cumbrians kept plugging away in a second half they had dominated but they were undone by another wicked deflection in time added on when Brunt sent a low ball into the box. Gillespie was left on the floor as it spun up and Wylde made a late claim to the strike as he volleyed it into the gaping net.
Plymouth - Brunt (26, 90)
United - Ellis (27), Archibald-Henville (86)
Plymouth - Nelson (67)
Carlisle United - Gillespie, Atkinson, Raynes, Ellis, Grainger, Gilliead, Kennedy, Joyce (Thompson 84), Sweeney (Dicker 56), Wyke, Asamoah (Archibald-Henville 84). Subs - Hanford, Miller, Hery, Gillesphey.
Plymouth Argyle - McCormick, Mellor, Sawyer, McHugh, Nelson, Hartley, Simpson, Wylde, Jervis (Tanner 50), Brunt, Threlkeld. Subs - Walton, Reid, Harvey, Purrington, Smalley, Rooney.
Referee - Mr Seb Stockbridge
Attendance - 4,415 (801 away fans)
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Pretty cool tea encyclopedia for Chinese teas that has pics and info on a lot of teas. Here is the section on greens -
Anyone seen this?
Made from leaves that have not been oxidized.
May 7th, '12, 16:28
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Re: Anyone seen this?
That's very cool! I like it that they keep everything simple and clear.
May 7th, '12, 16:55
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Re: Anyone seen this?
Yes indeed ... but since it is an "encyclopedia," it would be great if it was more alphabetized (by category). Especially as the list grows longer and longer.


text:
It was 5am and I must have been out of my mind. I was due to start a hard-core shift of cleaning, breakfast preparation and general elbow-greasing in an hour, but after losing a few rounds of the chalet girls' favourite drinking games and being jeered into gulping down a foul series of lurid green Tabasco sauce and liquorice-flavoured shooters, the dance floor had me trapped in a whirly headlock.
I didn't much remember tumbling into the chalet-hotel and didn't make my 6am shift - or the 7am, or the one that started at 8.30. My week as an undercover chalet-maid in St Anton was going off-kilter at the first bend, but I swore I'd soon embrace both halves of the 'work hard, play hard' chalet-girl motto, and muck in, toilet-cleaning and all.
I had agreed to work for Flexiski at the luxurious, 17-room, Amalien Haus chalet-hotel in the centre of St Anton, Austria's most famous party resort, and thought I knew the score. I'd taken chalet holidays before, enduring the commune-like atmosphere with strange and dysfunctional families, forcing down greasy grey fish soup and rubbery beef bourguignon cooked by some hapless 18-year-old. I'd heard stories of what really goes on - chalet maids sleeping with guests for tips, pretending it's their birthday every week so guests buy them presents, spending half the food budget on drugs, and watering down the wine so it goes further. Would I uncover such behaviour, survive the drinking, and be able to cope with scrubbing bogs and fending off bum-pinchers?
I felt welcomed into the Amalien fold and, with no guests for a couple of days, had a chance to get to know the staff. There was Dave the long-haired chef and his cute boarder girlfriend, who sat quietly at the kitchen table watching him chop and flambé each night, Matt and Kev, the cheeky chalet managers, Richard the Kiwi driver, Jess the rep/ski guide, and four girls, with whom I was soon chatting away about boys over vodkas. Matt said it was a relief I was young, or it would be harder to pass me off as a chalet girl. He also admitted that, while they were, of course, smart and efficient, the girls were partly hired for their drop-dead gorgeous looks, so the typical middle-aged male clientele would not be disappointed.
A big night out followed, setting the pattern for the week. We trawled through seasonaire haunt Scottie's, Bar Cuba, Bobo's, the tourist-riddled Piccadilly to watch the German rockers and Elvis-impersonator, then went clubbing in Kandahar and Postkeller till the early hours. When not partying, we worked hard, but the girls took turns to do breakfast, cleaning, afternoon cake-serving, canapés and drinks, dinner preparation and waitressing. Typically, they worked five or six hours a day, and would have the afternoon free to ski.
I seemed to have landed in the resort's most civilised job, and, rather unfortunately, the most well-behaved chalet. Aside from drinking, minor squabbling in the kitchen over weight-pulling and gentle bitching when guests ordered well-done steak, or hot chocolate after dinner ('He's 45, not 10 for God's sake!'), the Amalien staff were good as gold.
I found dirt elsewhere. In the infamous après-ski bar the Krazy Kanguruh - where there's much raucous table-dancing and getting your boobs out wins a bottle of champagne - a chalet girl with seven seasons under her apron told me about end-of-season 'panic shags', when conquest numbers are raised with less than ideal partners; that, like most chalet staff, she'd illicitly seduced a guest.
In the Kandahar nightclub, a big man in make-up and a gold sequinned minidress and balloon breasts cavorted with a blonde with a fake beard. It turned out that these were the Mark Warner hotel staff - known as the wildest workers in the resort - spending their one night off a week on a drag-themed outing.
In the Anton Cafe, resort workers spilt tales of guests getting naked and prancing round the kitchen, even of chalet girls joining in. I heard of hosts flogging stolen skis to their guests and taking too many drugs. Of pot-washers stealing crates of vodka, of workers being sacked for skipping shifts and of lots and lots of shagging around.
Cleaning was more complex than I thought possible - polishing windows with paraffin, buffing the fish tank, digging through balcony snow for ashtrays and separating rubbish into five different recycling bins. I cleaned toilets, washed up - eventually properly, after my plates were returned for sporting amoeba-sized specks. 'Smile and relax, be friendly,' Kev ordered when I was waitressing. No one pinched my bum, but one guest told me I had nice shiny cheeks and I listened to a lot of drunken ramblings. When my Faking It moment finally came, the guests had no trouble identifying the undercover reporter: 'You were lingering at the back, looking a bit confused.'
The work wasn't exactly fun, but it only constitutes half the chalet-girl experience. There was time for a few hours' skiing each day, interspersed with frequent stops for drinks and gossiping with other seasonaires.
The Flexiski staff had a good deal. They get paid around £85 a week, doubled with tips, plus free lift-passes, decent accommodation in a central apartment (sleeping two to a room, unlike in other companies, where there were eight). They ate the same three-course meals as the guests, had a licence to fridge-raid, unlimited chalet wine and could commandeer the sofas and telly when the guests were out.
They also had a fair amount of time off. 'Ah, I see the Flexiski girls are hard at work again,' we'd hear whenever we were out skiing or drinking, before a seasonaire from another company regaled us with tales of fussy guests, no time off for weeks and 10-hour shifts. Even so, I learnt that I probably couldn't hack being a chalet girl for a season. Oh, and I'm ashamed to say that I never made it for the 6am shift.
Rules of the game
Chalet maids are typically paid a pittance - around £50 a week, but make their money up in other ways. In bars for example, a two-tier economy operates - tourists typically pay £4 for a pint in St Anton. Chalet maids get around 30 per cent off. Entry to a club is free not £5.
Most British chalet maids are told 'you must not sleep with the clients'. Many do. 'We're told not to get up to any shenanigans with the guests,' one chalet maid told me, 'but almost everyone does.'
By mid-season several staff in each chalet will have a limb in plaster. Some will be skiing accidents; many are alcohol-related. St Anton is renowned for drink-fuelled accidents because of après-ski bars from which you have to ski back down. 'People put their skis on back to front,' says Gunnar Munthe, owner of the Krazy Kanguruh bar. 'We always offer to get them a taxi down, but we can't stop them.'
The low wages make tips vital, so don't be surprised if the staff who blanked you in the bar on Tuesday start getting very friendly by the end of the week. 'Of course a lot of chalet maids flirt with their guests in order to get tips - it's part of the job,' said one.
Resorts are a hotbed of bitching and backstabbing, so successful chalet maids form a clique. If you've no mates, you'll be condemned to hanging out with your guests - a sad fate.
Still fancy it?
www.natives.com has details of jobs available and a database of firms looking for workers. Recruitment takes place between July and October, though people often drop out, get injured or sacked, so jobs come up throughout the season.
Gemma Bowes stayed at the Amalien Haus chalet in St Anton, where four nights' half-board costs from £480 per person with Flexiski (0870 900 3278; www.flexiski.co.uk).
A lift pass covering St Anton and the Arlberg resorts costs £94 for four days. For further information contact the St Anton Tourist Board (00 43 544 622 690; www.stantonamarlberg.com).