text:
RECORD NOS. 992934 and 992935
HCA HEALTH SERVICES OF VIRGINIA, INC., et al.
STEPHEN M. LEVIN, M.D., et al.,
STEPHEN M. LEVIN, M.D., et al.
In Support of Appellants
Julia Krebs-Markrich, Va. Bar. No. 17698 Virginia Hackney, Va. Bar No. 05516
John E. Coffey, Va. Bar No. 19086 Marie Elena Graham, Va. Bar No. 42275
Heather L. Gunas, Va. Bar No. 42282 HUNTON & WILLIAMS
REED SMITH HAZEL & THOMAS LLP Riverfront Plaza, East Tower
3110 Fairview Park Drive, Suite 1400 451 East Byrd Street
Falls Church, Virginia 22042 Richmond, Virginia 23219
(703) 641-4200 (804) 788-8200
Counsel for all Amici Counsel for the Medical Society of Virginia
subject index
A. Identification Of Amici 1
B. Interest Of Amici 3
A. The Peer Review Process Is Essential To Providing Quality Health Care Services To Citizens Of The Commonwealth 8
B. The Purpose Of Virginia Code ' 8.01-581.17 Is To Ensure The Confidentiality Of The Peer Review Process 9
C. The Legislative History Of Virginia Code ' 8.01-581.17 Demonstrates
That The Peer Review Privilege Applies In All Contexts, Not Just
Medical Malpractice Cases 13
D. The Scope Of The Privilege 15
Bradburn v. Rockingham Mem. Hosp., 45 Va. Cir. 356 (Rockingham Co. 1998) 5, 11
Bredice v. Doctors Hosp., Inc., 50 F.R.D. 249 (D.D.C. 1970), aff'd w/o op., 479 F.2d 920 (D.C. Cir. 1973) 11
Etienne v. Mitre Corp., 146 F.R.D. 145 (E.D. Va. 1993) 11
Francis v. McEntee, 10 Va. Cir. 126 (Henrico Co. 1987) 5, 11, 13
Houchens v. Rector of the Univ. of Virginia, 23 Va. Cir. 202 (City of Charlottesville 1991) 18
Johnson v. Roanoke Mem. Hosps., Inc., 9 Va. Cir. 196 (City of Roanoke 1987) 5, 10, 11, 13
Klarfeld v. Salsbury, 233 Va. 277, 355 S.E.2d 319 (1987) 7
Mangano v. Kavanaugh, 30 Va. Cir. 66 (Loudoun Co. 1993) 5, 10, 11, 12, 13
Owens v. Children's Hospital, 45 Va. Cir. 97 (City of Norfolk 1997) 5
Rakes v. Fulcher, 210 Va. 542, 172 S.E.2d 751 (1970) 18
Stevens v. Lemmie, 40 Va. Cir. 499 (City of Petersburg 1996) 4, 5, 13-14
United States v. Mettatal, Crim. Action No. 96-0034-H, 1997 U.S. Dist. LEXIS 13974 (W.D. Va. Aug. 20, 1997) 17-18
White v. Cassady, 29 Va. Cir. 45 (Fairfax Co. 1992) 16
York v. Fairfax Hosp. Sys. Inc., 28 Va. Cir. 211 (Fairfax Co. 1992) 18
Va. Code ' 8.01-581.16 passim
Va. Code ' 8.01-581.17 passim
Va. Code ' 32.1-25 15
Va. Code § 37.1-84.1B 15
Va. Code ' 54.1-2906(A) 15
Va. Code ' 8-654.10 (1976 Cum. Supp.) 12, 14
Va. Code ' 8-911 - 8-922 (1976 Cum. Supp.) 12
Ala. Code § 22-21-8(b) (1999) 10
Alaska Stat. § 18.23.030 (1999) 10
Ariz. Rev. Stat. § 36-445.01 (1999) 10
Ark. Stat. Ann. § 20-9-503 (1999) 10
Cal. Evid. Code § 1157 (1999) 10
Col. Rev. Stat. § 13-21-110(1) (1998) 10
Conn. Gen. Stat. § 19a-17b (1999) 10
24 Del. Code Ann. § 1768 (1998) 10
D.C. Code Ann. § 32-505 (1999) 10
Fla. Stat. § 766.101 (1999) 10
Ga. Code Ann. § 31-7-143 (1999) 10
Hawaii Rev. Stat. Ann. § 624-25.5 (1999) 10
Idaho Code § 39-1392b (1999) 10
735 Ill. Comp. Stat. Ann. 5/8-2101 and 5/8-2102 (1999) 10
Ind. Code Ann. § 16-39-6-3 (1999) 10
Iowa Code § 147.135 (1997) 10
Kan. Stat. Ann. § 65-4915 (1998) 10
Ky. Rev. Stat. § 311.377(2) (1998) 10
La. Rev. Stat. § 13:3715.3 (1999) 10
32 Maine Rev. Stat. § 3296 (1998) 10
Md. Health Occ. Code Ann. § 14-501(d) (1999) 10
Mass. Ann. Laws ch. 111, § 204 (1999) 10
Mich. Comp. Laws § 333.21515 (1999) 10
Minn. Stat. Ann. § 145.64 (1999) 10
Miss. Code Ann. § 41-63-9 (1999) 10
Mo. Rev. Stat. § 537.035 (1999) 10
Mont. Code Ann.§ 50-16-203, 50-16-205 (1999) 10
Neb. Rev. Stat. Ann. § 71-2048 (1999) 10
Nev. Rev. Stat. § 49.265 (1999) 10
N.H. Rev. Stat. Ann § 151:13-a (1999) 10
N.M. Stat. Ann § 41-9-5 (1999) 10
N.Y. Educ. Law § 6527(3) (1999) 10
N.C. Gen. Stat. § 131E-95 (1999) 10
N.D. Cent. Code § 23-34-02 (1999) 10
Ohio Rev. Code Ann. § 2305.251 (Anderson 1999) 10
63 Okla. Stat. § 1-709 (199) 10
Or. Rev. Stat. § 41.675 (1997) 10
63 Pa. Stat. Ann. § 425.4 (1999) 10
R.I. Gen. Laws § 5-37.3-7 (1999) 10
S.C. Code Ann. § 40-71-20 (1998) 10
S.D. Codified Laws Ann. ' 36-4-26.1 (1999) 10
Tenn. Code Ann. § 63-6-219 (1999) 10
Tex. Rev. Civ. Stat. art. 4495b (1999) 10
26 Vt. Stat. Ann. § 1443 (1999) 10
Ann. Rev. Code Wash. § 4.24.250 (1999) 10
W. Va. Code Ann. § 30-3C-3 (1999) 10
Wis. Stat. § 146.38 (1998) 10
Wyo. Stat. § 33-26-408 (1999) 10
Acts of Assembly, Vol. 1, 1976 12
Report of the Virginia Code Commission, House Document No. 14, House and Senate
Documents, Vol. 1, 1977 12
Gosfield, Medical Peer Review Protection in the Health Care Industry,
52 Temple L.Q. 552 (1989) 4
Southwick & Slee, Quality Assurance in Health Care: Confidentiality of Information and
Immunity for Participants, 5 J. Legal Med. 343 (1984) 8
The Virginia Hospital and Healthcare Association, the Medical Society of Virginia, the American Medical Association, and the American Hospital Association submit this brief in support of the appellant hospitals Reston Hospital Center, Pentagon City Hospital, and Inova Health System (referred to collectively hereafter as "Hospitals"). This brief accompanies a Motion for Leave to File Brief Amicus Curiae.
The Virginia Hospital and Healthcare Association ("VHHA") is a private, nonprofit membership organization comprising over 90 percent of all hospital systems, acute care hospitals, psychiatric, rehabilitation and other specialty hospitals operating in the Commonwealth of Virginia. VHHA members include not-for-profit and for-profit hospitals, public and private hospitals, and rural and urban hospitals. Virginia hospitals care for over 690,000 patients of all ages each year on an inpatient basis. VHHA's principal purpose is to support the ability of Virginia hospitals to deliver comprehensive, high-quality and cost-efficient care to patients and to encourage access to necessary medical service.
The Medical Society of Virginia ("MSV") is the largest physician organization in Virginia and represents over 6,500 licensed doctors of medicine and osteopathy throughout the Commonwealth. MSV represents the concerns of Virginia physicians irrespective of specialty, employment arrangement, or practice setting. Through the efforts of MSV, physician views on health care issues are brought to the attention of Virginia and federal legislators, other governmental decision makers, as well as insurance companies, resulting in the advancement of individual and community health throughout the Commonwealth.
The American Medical Association ("AMA"), an Illinois non-profit corporation, represents approximately 300,000 physicians who practice throughout the United States, including Virginia. The AMA was founded in 1847 to promote the science and art of medicine and the betterment of public health, and these still remain its core purposes. AMA members practice in all fields of medical specialization, and it is the largest medical society in the United States.
The American Hospital Association ("AHA@) is the primary national membership organization for hospitals in the United States. The AHA=s mission is to promote high quality health care and health services through leadership and assistance to hospitals in meeting the health care needs of their communities. AHA's membership includes approximately 5,000 hospitals, health systems, networks and other providers of care.
Through their participation as Amici in this case, the VHHA, MSV, AMA and AHA seek to reinforce the Aoverriding national need to provide incentive and protection" for professional peer review expressed by Congress in the Health Care Quality Improvement Act of 1986, 42 U.S.C. '' 11101-11152 ("HCQIA@) and recognized by the Virginia General Assembly in its enactment of Virginia's peer review privilege statute, Virginia Code ' 8.01-581.17. Because their members depend upon peer review to assess and maintain the adequacy and quality of patient care they deliver, the Amici are among the organizations best qualified to speak on the importance of laws that encourage and protect peer review.
Peer review is a process by which professional medical activity is reviewed by other professionals with comparable education who have the skill and judgment necessary to evaluate the quality of medical services provided to patients and to identify the steps needed to improve patient outcomes. Effective peer review is vital to the ability of hospitals and medical staffs to protect patients from physicians who are incompetent or who engage in unprofessional behavior. It is also crucial to the ability of hospitals to engage in critical self-assessment of their functions. The importance of effective professional peer review to patients cannot be overstated: the process identifies problems and mistakes, and reduces or eliminates the potential for recurrence of harm. As a consequence, peer review improves patient outcomes and benefits the public health.
Immunity and confidentiality are the primary "incentive and protection" for effective peer review. The 1986-enacted HCQIA, for example, provides immunity from liability under almost all state and federal laws, including the antitrust laws, for peer review action taken in accordance with its standards. 42 U.S.C. § 11111. Virginia, like most other states, has long extended civil immunity to peer review participants and provides confidentiality for the peer review process, protecting from disclosure all communications, both oral and written, that originate in or are provided to peer review entities. Va. Code §§ 8.01-581.16, 581.17.
The confidentiality Virginia law accords peer review information is not intended to permit hospitals and physicians to act in secret, or to evade accountability for professional misjudgment. Rather, the purpose is to promote Afree-wheeling exchanges where criticisms are actually encouraged and mistakes or deficiencies aggressively exposed@ in furtherance of the overall goal of improvement of the system. See Stevens v. Lemmie, 40 Va. Cir. 499, 507 (City of Petersburg 1996). For example, confidentiality encourages a hospital department chair at one hospital to report the limitations of a physician to another hospital in which the physician seeks privileges; makes it easier for a physician to criticize a fellow physician; and emboldens a hospital to make systemic changes to its procedures that will improve patient outcomes.
There are powerful disincentives to effective peer review, the most significant of which may be the fear of retaliatory action. As one legal commentator has noted, Adoctors seem to be reluctant to engage in strict peer review due to a number of apprehensions: loss of referrals, respect, and friends, possible retaliations, vulnerability to torts, and fear of malpractice actions in which the records of peer review proceedings might be used.@ Gosfield, Medical Peer Review Protection in the Health Care Industry, 52 Temple L.Q. 552, 558 (1989). If peer review information were not confidential, there would be little incentive to participate in the process. For example, a physician who criticizes the performance or conduct of another physician will consider the time and expense of defending against possible defamation or antitrust claims (even if immunity were to prevent a judgment), as well as the potential for uncollegial conduct from colleagues. Or, in the case of a nurse speaking out against a physician, disclosure of the information given to a peer review committee may pose a threat of losing a job. Similarly, a hospital engaged in critical self-assessment may consider how the information it generates could constitute an admission against interest in a lawsuit or be otherwise misinterpreted.
While as yet no appellate cases in Virginia clearly articulate the metes and bounds of the privilege set forth in ' 8.01-581.17, the circuit courts, while arriving at various conclusions as to whether particular documents are within the purview of the privilege, have generally agreed that the purpose of Virginia Code ' 8.01-581.17 is to promote open and frank discussion without concern that remarks will be made public. See, e.g., Bradburn v. Rockingham Mem. Hosp., 45 Va. Cir. 356, 360 (Rockingham Co. 1998); Owens v. Children's Hospital, 45 Va. Cir. 97, 99-100 (City of Norfolk 1997); Stevens v. Lemmie, 40 Va. Cir. at 507; Mangano v. Kavanaugh, 30 Va. Cir. 66, 68 (Loudoun Co. 1993); Francis v. McEntee, 10 Va. Cir. 126, 128 (Henrico Co. 1987); Johnson v. Roanoke Mem. Hosps., Inc., 9 Va. Cir. 196, 198 (City of Roanoke 1987).
In this case, the Fairfax County Circuit Court has ordered the non-party Hospitals to produce records pursuant to a subpoena duces tecum. The Hospitals assert that the records requested are confidential peer review records and, thus, subject to protection from disclosure under § 8.01-581.17 of the Code of Virginia. The Circuit Court's ruling in this case compromises an important protection for those who participate in the peer review process. The precedent will gravely impair the ability of Virginia hospitals and physicians to evaluate and correct medical errors.
As the two largest healthcare organizations in Virginia, the largest medical society in the country, and the primary hospital organization in the United States, the VHHA, MSV, AMA and AHA are best qualified to speak for hospitals on this issue. The VHHA and MSV were instrumental in persuading the General Assembly to adopt laws that protect and encourage the peer review process, just as the AMA and AHA played a critical role in the enactment of the HCQIA. The members of the VHHA, MSV, AMA and AHA share a keen interest in seeing that judicial construction does not weaken such laws by interpretations that fail to take into account the overarching importance to the public of protecting the peer review process.
The Circuit Court erred in ordering the disclosure of hospital peer review records that are privileged pursuant to Virginia Code ' 8.01-581.17.
1. Whether the privilege accorded by Virginia Code ' 8.01-581.17 to hospital peer review records is applicable only in medical malpractice actions?
2. Whether the privilege accorded by Virginia Code ' 8.01-581.17 to hospital peer review records may be waived unilaterally by an individual physician who is the subject of peer review proceedings?
3. Whether WJLA-TV has demonstrated good cause arising from extraordinary circumstances, as required by Virginia Code ' 8.01-581.17, to justify the disclosure of confidential peer review records?
The Amici adopt the Statement of the Case as stated by the Appellants.
The Amici adopt the Statement of the Facts as stated by the Appellants.
Virginia law encourages and protects peer review through two important mechanisms: 1) granting immunity to those who participate in the peer review process; and 2) restricting access to peer review information. Section 8.01-581.16 of the Code of Virginia, among other sections, extends immunity to those who participate in the peer review process. This Code section states in pertinent part that members of peer review committees "shall be immune from civil liability for any act, decision, omission, or utterance done or made in performance of [their] duties . . . ." Va. Code § 8.01-581.16. This prong of the Virginia statutory scheme protects peer review participants from, inter alia, retaliatory lawsuits by health care providers who are the subjects of the peer review process.
Section 8.01-581.17 of the Code of Virginia provides a "privilege in plain language." See Klarfeld v. Salsbury, 233 Va. 277, 284, 355 S.E.2d 319, 323 (1987). This privilege protects the proceedings and all communications to and from peer review committees, as defined in Virginia Code ' 8.01-581.16, from disclosure or discovery. Such proceedings and communications expressly include documents related to the adequacy or quality of a physician's performance and whether such physician has been disciplined. See Va. Code '' 8.01-581.17 and 581.16(iv), (v). The plain language and legislative history of the statute extend the privilege to all disclosures and to all legal discovery proceedings. The statute does not limit the privilege to discovery in medical malpractice proceedings.
Section 8.01-581.17 of the Code of Virginia encourages candid and critical assessment. The statute does not provide that the privilege can be waived. Permitting the subject of a peer review proceeding to Awaive@ the protection afforded peer review records and communications is contrary to the plain language of the statute and severely compromises the protection the Virginia legislature saw fit to afford the peer review process. In the end, such disruption of the peer review process would negatively affect the public health and welfare.
The broad privilege set forth in Virginia Code ' 8.01-581.17 is not absolute; however, a circuit court may order disclosure of peer review documents only after a hearing for good cause arising from extraordinary circumstances being shown. The Virginia courts have interpreted the "good cause" escape clause restrictively; there must be a demonstration of exceptional circumstances. In this case, WJLA-TV has not demonstrated sufficient facts to establish good cause arising from extraordinary circumstances.
The circuit court in this case wrongly determined that the peer review privilege embodied in Virginia Code ' 8.01-581.17 is limited to medical malpractice actions. Such a conclusion ignores the plain words of the statute as well as the statute's legislative history. Moreover, such a conclusion violates the intent of the General Assembly that the peer review process be subject to confidentiality so as to promote and encourage participation in the peer review process. Finally, the Virginia General Assembly has, in other sections of the Virginia Code, recognized that ' 8.01-581.17 applies in situations outside of the medical malpractice arena.
A. The Peer Review Process Is Essential To Providing Quality Health Care Services To Citizens Of The Commonwealth.
Peer review is the process by which professional practice is assessed and measured by other professionals of similar training. It involves Asetting standards of care, reviewing cases to determine whether the standards are being met, recommending and implementing methods to improve substandard care, and subsequent reviews of care to determine whether goals have been achieved.@ Southwick & Slee, Quality Assurance in Health Care: Confidentiality of Information and Immunity for Participants, 5 J. Legal Med. 343, 346 (1984).
Hospitals use peer review to determine whether physician applicants for clinical privileges have the necessary credentials and training to obtain clinical privileges. For example, in assessing the competence of a physician applicant, hospitals ask the physicians who trained or recently observed the clinical practice of the applicant to make recommendations as to the competency of the physician applicant. Hospitals also use peer review on an ongoing basis to review the competency of medical care provided by a physician after clinical privileges have been awarded. In such cases hospitals seek evaluations from physicians also practicing in the hospital and, on occasion, from outside sources such as independent quality assurance consultants. In addition, hospitals use peer review to evaluate complaints brought against the hospital or hospital physicians from any source, including other physicians, nurses and patients. Finally, hospitals use peer review to evaluate their own procedures and to determine whether improvements can or should be make to reduce errors and complications.
For obvious reasons, peer review is only as good as the candor the "peer reviewer" exercises in making his/her evaluation. If peer review evaluations are easily subject to disclosure, peer reviewers will be reluctant to speak their minds for fear of subjecting themselves not only to retaliatory action but also to the expenditure of time and effort necessary to defend their evaluations. Within a short time, peer review will have little meaning or substance and the process will become degraded. The result will be harm to the public. It is through the constant scrutiny of the peer review process that patients are protected from substandard care, through the imposition of monitoring and consultation requirements or, ultimately, through formal disciplinary actions, such as reduction, suspension or termination of clinical privileges or staff membership.
B. The Purpose Of Virginia Code ' 8.01-581.17 Is To Ensure The Confidentiality Of The Peer Review Process.
Section 8.01-581.17 of the Code of Virginia provides in pertinent part that
[t]he proceedings, minutes, records, and reports of any . . . medical staff committee, utilization review committee, or committee as specified in ' 8.01-581.16 . . . together with all communications, both oral and written, originating in or provided to such committees . . . are privileged communications which may not be disclosed or obtained by legal discovery proceedings unless a circuit court, after a hearing and for good cause arising from extraordinary circumstances being shown, orders the disclosure of such proceedings, minutes, records, reports, or communications.
This privilege extends to all communications originating from or provided to the specified medical committees. See Mangano v. Kavanaugh, 30 Va. Cir. 66, 68 (Loudoun Co. 1993). The objective of the privilege is to protect peer review by encouraging open discussion and vigorous debate within the hospital without the concern that remarks may be made public. See Johnson v. Roanoke Mem. Hosps. Inc., 9 Va. Cir. 196, 198 (Roanoke 1987). At least forty-eight states and the District of Columbia have adopted laws that protect the confidentiality of peer review information, demonstrating a national consensus that such confidentiality serves an important public policy.
Confidentiality is essential to the integrity of the hospital peer review process. As the court noted in Bredice v. Doctors Hosp., Inc., 50 F.R.D. 249 (D.D.C. 1970), aff'd w/o op., 479 F.2d 920 (D.C. Cir. 1973), one of the first federal cases dealing with the issue,
[c]andid and conscientious evaluation of clinical practices is a sine qua non of adequate hospital care. To subject these discussions and deliberations to the discovery process, without a showing of exceptional necessity, would result in terminating such deliberations.
Id. at 250. In Virginia, one circuit court has been more blunt, observing that "[t]he whole procedure of peer review, if it is to have meaning and substance, must be totally uninhibited from the fear of disclosure." See Johnson v. Roanoke Mem. Hosps., 9 Va. Cir. at 198. See also Bradburn v. Rockingham Memorial Hospital, 45 Va. Cir. 356, 360 (Rockingham Co. 1998) (stating that "[i]t is certainly clear that the legislature has determined as a matter of public policy in Virginia that many of the documents utilized in, by, and with [peer review committees] are to be exempt from discovery . . . in order to facilitate the free flow of information between staff personnel and [the committees]"); Mangano v. Kavanaugh, 30 Va. Cir. at 68 (noting that the "legislature recognized the need for privacy in order to promote the type of vigorous debate where such open exchanges could be made without fear of public disclosure. Indeed, without protection from disclosure such discussions would probably be meaningless and without substance"); Francis v. McEntee, 10 Va. Cir. 126, 128 (Henrico Co. 1987) (explaining that the legislature "clearly made a public policy decision that it is in the best interests of the public to foster unrestrained dialogue among boards, staffs and committees of health care providers.") See also Etienne v. Mitre Corp., 146 F.R.D. 145, 147 (E.D. Va. 1993), citing Bredice v. Doctors Hospital, 50. F.R.D. 249, 251 (D.D.C. 1970) (describing under the "self-critical analysis privilege," a precursor to the statutory peer review privilege, the court's recognition that the "long-term public benefits of improved health care outweighed the needs of the litigant seeking discovery"). The statute thus should be read broadly, effecting the legislature's intent to "afford the utmost protection" to peer review records and communications. Mangano v. Kavanaugh, 30 Va. Cir. at 68.
C. The Legislative History Of Virginia Code ' 8.01-581.17 Demonstrates That The Peer Review Privilege Applies In All Contexts, Not Just Medical Malpractice Cases.
The legislative history of Virginia Code ' 8.01-581.17 demonstrates that that section was intended to operate as a general privilege and not a privilege applicable only in medical malpractice cases. Prior to 1977, the privilege contained in now ' 8.01-581.17 was found in the "miscellaneous actions" section of Chapter 29 of Title 8 and was not part of the Virginia statutes dealing with malpractice actions. See ' 8-654.10 of the Code of Virginia (1976 Cum. Supp.). The medical malpractice provisions were contained separately in Chapter 39 of Title 8. See '' 8-911 through 8-922 of the Code of Virginia (1976 Cum. Supp.). It is important to note that the statutes were in separate sections of the Code even though they were enacted at the same time. See Acts of Assembly, Vol. 1, 1976 at 784.
In 1977, the General Assembly recodified the Virginia Code, repealing Title 8 and enacting Title 8.01 in lieu thereof. In moving ' 8-654.10 into ' 8.01-581.17 of the Code of Virginia, the Reviser's Note made clear that the substance of the original statute was preserved. Report of the Virginia Code Commission, House Document No. 14, at 330, House and Senate Documents, Vol. 1, 1977.
The Virginia Code Commission noted that the objective of recodification was to devise the "best procedural system conceivable without doing violence to that portion of the existing system which had proved, on the basis of experience, to be of value in Virginia." See Report of the Virginia Code Commission, House Document No. 14 at 3, House and Senate Documents, Vol. 1, 1977. Accordingly, one cannot infer from the movement of ' 8-654.10 from Chapter 29 into the successor to Chapter 39, any indication that the generally applicable privilege set forth in the original ' 8-654.10 was henceforth to apply solely to malpractice claims.
D. The Scope Of The Privilege.
In enacting ' 8.01-581.17 and its predecessor, the General Assembly fully considered the interest of plaintiffs in civil actions in obtaining full disclosure, and the interest of the public at large in being able to benefit from "open and frank discussion >where criticisms are actually encouraged and mistakes or deficiencies aggressively exposed . . . .=" See Mangano v. Kavanaugh, 30 Va. Cir. at 68, citing Johnson v. Roanoke Mem. Hosps., 9 Va. Cir. at 198. In the end, the General Assembly determined that it was more in the interest of the public to foster unrestrained dialogue among boards, staffs and committees of health care providers. Francis v. McEntee, 10 Va. Cir. at 128 ("By enactment of [' 8.01-581.17], the Virginia General Assembly has clearly made a public policy decision that it is in the best interests of the public to foster unrestrained dialogue among boards, staffs and committees of health providers. Health care providers should be encouraged to adopt policies and procedures which will provide the public with the highest degree of care recognized by the medical and scientific communities at any given time.").
With the Virginia General Assembly having tipped the scale in favor of promoting self-critical analysis, there would be no purpose in applying the prohibition on discovery only to plaintiffs in medical malpractice cases. In fact, except for the decision under appeal in this case, no court has ever determined that the privilege embodied in ' 8.01-581.17 is limited to a particular context, let alone medical malpractice.
For example, in Stevens v. Lemmie, the Circuit Court of the City of Petersburg examined the application of the peer review privilege to a Freedom of Information Act ("FOIA") request made in a wrongful death case. 40 Va. Cir. 499 (City of Petersburg 1996). In interpreting the language of Section 8.01-581.17, the Court noted that
[I]t has been suggested that the term "legal discovery proceedings"
should apply only to discovery pursuant to the Rule of Court incident
to a pending legal proceeding. But the literal language of the statute
and the public policy advanced by the statute do not support such a
narrow interpretation. A FOIA action is certainly a "legal proceeding"
and its purpose is to "discover" information.
Id. At 505. The court further stated that "it is inconceivable that the legislature meant to compromise the medical care rendered at public hospitals by allowing such communications to be discovered by FOIA requests . . . the literal reading of the statute and the public policy supporting it require that ' 8.01-581.17 provide an exception to disclosure under FOIA actions." Id. at 506. By dismissing the idea that the privilege would protect peer review information only when sought in connection with formal "discovery" in legal action, ostensibly any legal action, the Stevens holding invalidates the Circuit Court's even narrower interpretation rendering the privilege applicable only in medical malpractice actions.
The conclusion that the privilege embodied in Virginia Code ' 8.01-581.17 extends to all legal discovery is consistent with the plain language of the statute. Virginia Code ' 8.01-581.17 and its predecessor, ' 8-654.10, protect expressly the proceedings of certain hospital committees from "disclosure," or in the alternative, from "legal discovery proceedings." The words of the statute are plain and unambiguous: the privilege encompasses "disclosure" and "legal discovery" generally; the privilege is not limited expressly to discovery in medical malpractice cases.
The Circuit Court's error in limiting Virginia Code § 8.01-581.17 to medical malpractice actions is further demonstrated by examining the companion statute affording immunity to participants in the peer review process. Virginia Code ' 8.01-581.16 provides a general immunity from Acivil liability for any act, decision, omission, or utterance done or made in performance of his duties." Va. Code ' 8.01-581.16. This code section, as is the case with ' 8.01-581.17, appears in the Amedical malpractice@ section of the Virginia Code. No serious argument can be made, however, that this broad grant of immunity applies only in Amedical malpractice cases.@ To so construe this statute would eviscerate the very protection the General Assembly intended to confer. The same rationale applies in construing the provisions of Virginia Code ' 8.01-581.17.
The conclusion that the privilege contained in Virginia Code ' 8.01-581.17 extends beyond medical malpractice is also demonstrated by Virginia statutes governing other types of legal proceedings. For example, the State Health Commissioner has vast jurisdiction over the public health and the environment. Despite the extensive inquisitive authority the Commissioner enjoys, she does not have access to peer review documents. Section ' 32.1-25 of the Code expressly exempts from the reach of the State Health Commissioner Aprivileged communications pursuant to ' 8.01-581.17." Accordingly, the General Assembly has recognized that the privilege embodied in ' 8.01-581.17 applies outside of the medical malpractice context.
Other agencies have similar broad investigatory authority and peer review communication is similarly protected. See, e.g., Va. Code ' 54.1-2906(A) (Section 8.01-581.17 does not bar hospitals from reporting certain information to the Board of Medicine); Va. Code § 37.1-84.1B (excludes peer review records from the reach of the Department of Mental Health, Mental Retardation and Substances Abuse Services in their investigation of abuse, neglect, and human rights violations). These sections also demonstrate how carefully the General Assembly has guarded the confidentiality of the peer review process. Accordingly, the Circuit Court's finding that Virginia Code ' 8.01-581.17 Ais not applicable outside of the context of medical malpractice actions@ is incompatible with the language, history and purpose of the statute, and with other parts of the Code of Virginia.
The reliance of the Circuit Court on any waiver of privilege by Dr. Levin was misplaced. Indeed, allowing Dr. Levin to waive the protections of ' 8.01-581.17 is counter to the purpose and language of the peer review statute. The privilege granted in ' 8.01-581.17 is not akin to other evidential privileges.
First, the law was enacted to ensure confidentiality for the discussion and deliberation of physicians participating in the review of their peers. To place the ability to waive this privilege in the hands of the subject of the peer review activities jeopardizes the vital protection surrounding the process.
Secondly, the plain language of ' 8.01-581.17 does not permit a waiver of the peer review privilege. The statute states categorically that communications Aoriginating in or provided to [peer review committees] are privileged communications which may not be disclosed or obtained by legal discovery proceedings . . . .@ Va. Code § 8.01-581.17 (emphasis added). The General Assembly has clearly determined that the privilege is so important that it is not waivable by any hospital or physician and generally overrides the public need for discovery in legal proceedings. Only a court may order disclosure and then only after a hearing for good cause arising from extraordinary circumstances. Were a physician's or hospital=s waiver sufficient for the court to order disclosure, there would be no purpose in requiring a hearing to defeat the privilege.
Even assuming that the privilege contained in Virginia Code ' 8.07-581.17 can be waived, it cannot be waived by Dr. Levin. In this regard, a circuit court case deciding a similar issue determined that the privilege belongs to those conducting the peer review and not to the subject of the peer review. In White v. Cassady, 29 Va. Cir. 45 (Fairfax Co. 1992), Dr. White, the subject of peer review communications, asserted that he should be allowed to waive the privilege against disclosure and discovery in order to further his defamation action against Dr. Cassady, a physician consultant retained by a medical center to undertake a peer review study of Dr. White. The Circuit Court of Fairfax found that Dr. Cassady=s report regarding Dr. White was privileged and protected from disclosure and discovery, and, that Dr. Cassady was entitled to assert the
' 8.01-581.17 privilege, not Dr. White. Id. Applying the same rationale to this case, Dr. Levin would be unable to waive the privilege under ' 8.01-581.17, even if he desired to do so.
Allowing the subject of a peer review proceeding to Awaive@ the protections of Virginia Code ' 8.01-581.17 is counterintuitive to the purpose of the statute. The legislature enacted § 8.01-581.17 to ensure confidentiality of the discussions and deliberations of physicians participating in the review of their peers for the greater good of the public. To place the ability to waive this privilege in the hands of the subject of the peer review activities compromises the protection afforded the process, and potentially exposes the public to a greater risk of treatment by incompetent physicians. The reliance of the Circuit Court on any waiver of privilege by Dr. Levin was misplaced.
Virginia has long protected peer review records from disclosure or legal discovery except when there has been a demonstration of good cause arising from extraordinary circumstances. Va. Code ' 8.01-581.17. As noted by the U.S. District Court for the Western District of Virginia, "[n]o Virginia case law specifically addresses what might serve as >good cause= to overcome [' 8.01-581.17's] privilege, but, self-evidently, the burden is quite high." United States v. Mettatal, Crim. Action No. 96-0034-H, 1997 U.S. Dist. LEXIS 13974, at *5 (W.D. Va. Aug. 20, 1997) (emphasis added).
The test for good cause was explained in Rakes v. Fulcher, 210 Va. 542, 172 S.E.2d 751 (1970). In that case, the court held that the moving party must establish good cause by something more than relevancy. Moreover, the party seeking discovery must show a "bona fide effort to obtain the information by independent investigation." 210 Va. at 456, 172 S.E.2d at 755.
In this regard, circuit courts have held that good cause does not exist where the plaintiff in a medical malpractice case has the opportunity to depose individuals to ascertain the facts that are at issue. Id. See also York v. Fairfax Hosp. Sys. Inc., 28 Va. Cir. 211, 212 (Fairfax Co. 1992) (no good cause exists where the defendant was able to identify persons having personal knowledge of the relevant facts underlying the disputed documents); Houchens v. Rector of the Univ. of Virginia, 23 Va. Cir. 202, 204 (City of Charlottesville 1991) (the fact that the plaintiff was unconscious at the time of the alleged injury was insufficient to demonstrate extraordinary circumstances since the plaintiff had the opportunity to depose individuals who had personal knowledge of the events at issue).
Finally, the word "extraordinary" must be construed according to its plain meaning. See Houchens, 23 Vir. Cir. at 204 . The need for WJLA-TV to establish a defense against Dr. Levin is not "extraordinary," since a defense, which must be made in all legal proceedings, is the essence of usual and ordinary. Deeming the need to establish a defense as "extraordinary" would allow any defendant to overcome quite easily the protections of Virginia Code ' 8.01-581.17 -- a result that would undermine the purpose of the statute.
For the reasons set forth herein, the VHHA, MSV, AMA and AHA respectfully request the Court to overturn the prior rulings of the Fairfax Circuit Court and find the Hospitals not in contempt of Court.
Respectfully submitted,
By Counsel
Julia Krebs-Markrich, Va. Bar. No. 17698
John E. Coffey, Va. Bar No. 19086
Heather L. Gunas, Va. Bar No. 42282
3110 Fairview Park Drive
Suite 1400
Falls Church, VA 22042
(703) 641-4200
Counsel for all Amici
Virginia Hackney, Va. Bar No. 05516
Marie Elena Graham, Va. Bar No. 42275
Riverfront Plaza, East Tower
451 East Byrd Street
Richmond, Virginia 23219
(804) 788-8200
Counsel for the Medical Society of Virginia
Of Counsel:
Michael L. Ile, Esq.
Anne M. Murphy, Esq.
Leonard Nelson, Esq.
515 N. State Street
Chicago, Illinois 60610
(312) 464-5532
Maureen Mudron, Esq.
Washington Counsel
325 Seventh Street, N.W.
Washington, DC 20004
(202) 626-2301
I hereby certify that I have complied with Rule 5:26(d), Rules of the Supreme Court of Virginia, by causing to be filed on the 1st day of February, 2000 twenty (20) copies of the foregoing BRIEF AMICUS CURIAE OF THE VIRGINIA HOSPITAL AND HEALTHCARE ASSOCIATION, MEDICAL SOCIETY OF VIRGINIA, AMERICAN MEDICAL ASSOCIATION and AMERICAN HOSPITAL ASSOCIATION with the Supreme Court of Virginia, and causing on this same date to be mailed, first class, postage prepaid, three (3) copies of the foregoing to the following:
Robert T. Adams, Esq.
E. Duncan Getchell, Jr., Esq.
Sean F. Murphy, Esq.
McGUIRE WOODS BATTLE & BOOTHE LLP
One James Center
Richmond, Virginia 23219
Counsel for Appellants HCA Health Services of Virginia, Inc., et al.
William L. Carey, Esq.
McCANDLISH & LILLARD, P.C.
11350 Random Hills Rd., Suite 500
Fairfax, Virginia 22030
Counsel for Appellant Inova Health System
John B. Williams, Esq.
Kerrie L. Hook, Esq.
Thomas W. Mitchell, Esq.
3050 K Street, N.W., Suite 400
Washington, D.C. 20007
Counsel for Stephen M. Levin, M.D.
David J. Branson, Esq.
Steven C. Dubuc, Esq.
Paula J. McGill, Esq.
1050 Thomas Jefferson Street, N.W.
Washington, DC 20007
Counsel for Appellees WJLA-TV, Candace Mays, Archie Kelly, Albritton Communications Company, Albritton Group, Inc., and Perpetual Corporation
Mark L. Early, Esquire
Attorney General
900 East Main Street
Richmond, Virginia 23219
Julia Krebs-Markrich


text: Discover manufacturing and agriculture's role in the history of China as we explore Chinese culture through artifacts and relics. Chinese archaeology is one of the fastest growing and most exciting fields of study in China. With a wealth of cultural relics unearthed this past century, the world's fascination with China's rich history has been renewed.

subset: commoncrawl


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This is a Complete parts set for assembling 2 large-bore rear shock absorbers for the XRAY XT8. Includes dark blue (hard) springs.
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text:
Dear Tom and Vera
Thanks for this very useful lesson. It is a very well recorded lesson. Prior to this I never knew that ma3 shang4 and li4ke4 had a difference in meaning. But there is another word that I often hear native Chinese speaker use - 赶紧.
I\\'d appreciate if you can tell me the difference between 赶快 and 赶紧?
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text:
Cute Purple Room Escape
Mystery of the Missing Key Escape Use Mouse Only.Imagine that you were traveling in a snowfall city all alone for a vacation. Everything was going fine. You were sleeping in the living place. In the morning, you have noticed that you have missed the key and you were trapped. Find the answer to the puzzles to locate the missing key. Have fun in escape games. Click for more escape games
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text:
Definitions for frequently used inertial sensor terms
Accelerometer Glossary
The average over a specified time of accelerometer output measured at specified operating conditions that has no correlation with input acceleration or rotation. Bias is a signed quantity usually expressed in units of acceleration.
Composite Error
In general, any error that includes two or more sources; specific meaning is generated by naming the sources. More in detail, it is the maximum deviation of the output data from a specified output function. Composite error is due to the composite effects of hysteresis, resolution, nonlinearity, nonrepeatability, and other uncertainties in the output data. Errors Sources are typically RSS'd to obtain composite error.
Unit of acceleration, equal to a standard value of gravity or an otherwise specified level.
Undesired perturbations in the accelerometer output signal which are generally uncorrelated with desired or anticipated input accelerations. Noise in the accelerometer output is of two types: intrinsic and seismic.
Intrinsic noise is generated within the accelerometer and represents the limiting factor in making measurements. Intrinsic noise is random in nature and is characterized by a noise power spectral density (PSD) curve.
Seismic noise is a true input acceleration (usually unanticipated by the user). It results from noise sources in the local environment (running motors, seismic shocks, etc.) and their transmission to the accelerometer through the mounting structure which supports the accelerometer.
The closeness of agreement among measurements of the same variable, repeated under the same conditions, especially when changes in conditions occur or when operation is interrupted between the measurements
Scale Factor
The ratio of the change in output (in volts or amperes) to a unit change of the input (in units of acceleration); thus given in mA/g or V/g.
The ratio of a change in response to a change in an undesirable or secondary input (as the scale factor variation to a unit of power supply voltage change).
Temperature Modeling
The process by which performance characteristics are measured over the operating temperature range and mathematically reduced to obtain a constant and coefficients for a multi-order model. The model is normalized to one temperature (typically 20°C). The application of the model to raw data is referred to as 'correction'.
Temperature Sensitivity
The sensitivity of a given performance characteristic (typically scale factor, bias, or axis misalignment) to operating temperature. Specified as worst case value over the full operating temperature range. Expressed as the change of the characteristic per degree of temperature change; a signed quantity, typically in ppm/°C for scale factor, mg/°C for bias, and mrad/°C for axis misalignment.
Vibration Rectification Coefficient (VRC)
A calculated number obtained by dividing the bias shift that occurs during vibration (rms)2 value of the applied input vibration. Usually expressed in mg/g2 units.
Vibration Rectification Error(VRE)
The apparent shift in accelerometer bias when subjected to sinusoidal or random vibration due to the accelerometers even order non-linearity. Usually expressed in mg or g units with a specified vibration applied
Gyroscope Glossary
The specified maximum input rate (°/sec) over which full performance will be provided.
Full Range Output
The nominal voltage output for the specified full range input. The actual voltage output will be a complex compilation of several parameters including scale factor, bias, linearity and temperature characteristics.
Scale Factor
The ratio of the change in output (in volts or amperes) to a unit change of the input (in units of angular rates); thus given in mA/(°/s) or V/(°/s).
The average over a specified time of gyro output measured at specified operating conditions that has no correlation with input rotation or acceleration. Bias is typically expressed in degrees per
hour (°/h).
Bias Thermal Sensitivity
The bounds within which the Bias may vary as the temperature varies across the operating temperature range, included in the "Over Operating Environments" specification.
Bias Instability
The random variation in bias as computed over specified finite sample time and averaging time intervals (e.g. over 100 s or 1 day).
Output Noise
Self-generated electrical noise is defined by its power-spectral-density (PSD) and given in volts-squared per Hz over a given range of frequency. This defines the distribution of noise power in the output of the instrument, on a per-Hz basis.
MTBF: Mean Time Between Failures
The predicted elapsed time between inherent failures of a system during operation
The gyroscope operates from DC (zero frequency) to some upper frequency (typically defined by the frequency in which the frequency response function magnitude is down by 3 dB).
The maximum difference, at a fixed temperature, between bias readings during a full range excursion of input rates - first measured at zero input rate after having just returned from negative full range; and second, that bias reading measured at zero input rate after having just returned from positive full range.
Start-up Time
The time required for the instrument to produce a usable rate output after power application
Vibration - Operating
The specified limit of random vibration in g-RMS, usually across the flat 20 Hz - 2,000 Hz input spectrum range, which the device will withstand while operating within its performance specifications or dedicated performance range.
Vibration - Survival
The specified limit of random vibration (usually expressed in g-RMS over a defined frequency bandwidth) which the device will survive for a limited period of time without damage.
The limit of shock which the device will withstand without damage.


text:
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Chayote (Sechium edule), also known as christophene or christophine, cho-cho, mirliton or merleton (Creole/Cajun), chuchu (Brazil), Cidra (Antioquia, Caldas, Quindio and Risaralda regions of Colombia), Guatila (Boyacá and Valle del Cauca regions of Colombia), Centinarja (Malta), pimpinela
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text:
I hate it
Most Helpful Girl
I don't really care. They just added a bunch of stuff that I don't think I'll really use.11|00|0
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text:
Caffeine is used by the masses on a daily basis to increase wakefulness, alleviate fatigue, and improve concentration and focus.
In fact, caffeine is the most commonly used drug in the world.
Since caffeine is consumed so widely, there are a lot of half-truths, hearsay, urban legends, media hype, and even fiction surrounding the substance. In this article, we will clear up some of these misunderstandings.
Although the consumption of low to moderate doses of caffeine is generally safe and has proven health benefits, long-term excessive caffeine intake is a potential risk factor for certain health problems.
Contents of this article:
Here are some key points about caffeine. More detail and supporting information is in the main article.
- At least 68 million Americans drink three cups of coffee every day.
- Over 21 million Americans drink six or more cups of coffee every day.
- It is believed that some 3 out of 4 regular caffeine users are "addicted" to the substance.
- Around 5 grams of caffeine can be fatal. This is the equivalent of 30-40 cups of regular coffee.
What is caffeine?
More than 90 percent of adults in the U.S. use caffeine regularly.
The Food and Drug Administration (FDA) describes caffeine as both a drug and a food additive; it is used in prescription and OTC medicines to treat tiredness, drowsiness, and to improve the effect of some pain relievers.
The chemical formula is C8H10N4O2. Caffeine can be prepared by extraction from natural sources or synthesized from uric acid.
Caffeine belongs to a group of medicines called central nervous system (CNS) stimulants. In conventional foods, caffeine can help restore mental alertness.
Caffeine's use as an alertness aid should only be occasional. It is not intended to replace sleep and should not regularly be used for this purpose.
In the U.S., more than 90 percent of adults use caffeine regularly, with an average consumption of more than 200 milligrams of caffeine per day - more caffeine than in two 6-ounce cups of coffee or five 12-ounce cans of soft drink.
Where is caffeine found?
Caffeine occurs naturally in the leaves, seeds, or fruit of more than 60 plant species, including:
- Coffee beans - seed
- Tea leaves - leaves, bud
- Kola nuts - seed
- Cacao beans - seed
- Guarana - seed
- Yerba mate - leaf
- Yoco - bark
Caffeine acts as a natural pesticide for plants; it paralyzes and kills insects that attempt to feed on them.
Caffeine no longer only features in tea, coffee, and chocolate; it is regularly added to gum, jelly beans, waffles, water, syrup, and more.
In response to the trend of "added caffeine" in a growing number of products, the FDA is investigating the safety of caffeine in foods and particularly its effects on children and adolescents.
"Energy drinks" with caffeine are considered by some to be aggressively marketed, particularly to young people, with additional products appearing on the market, from "psyched up" oatmeal to "wired" waffles.
Caffeine is even being added to marshmallows, sunflower seeds, and other snacks for its stimulant effect.
Caffeine content in products
For healthy adults, about 4 or 5 cups of coffee a day is an amount not associated with dangerous or negative side effects.
For healthy adults, the FDA has cited 400 milligrams of caffeine a day - about 4 or 5 cups of coffee - as an amount not associated with dangerous or negative side effects.
The FDA has not set an amount for children, but the American Academy of Pediatrics discourages the consumption of caffeine and other stimulants by children and adolescents.
The amount of caffeine included in some common foods and beverages are:
- Coffee, brewed - 102 -200 milligrams per cup
- Coffee, instant - 27-173 milligrams per cup
- Coffee, decaffeinated - 3-12 milligrams per cup
- Tea, brewed American - 40-120 milligrams per cup
- Tea, brewed imported - 25-110 milligrams per cup
- Tea, instant - 28 milligrams per cup
- Tea, canned iced - 22-36 milligrams per 12 ounces
- Caffeine-containing cola and other soft drinks - 36-71 milligrams per 12 ounces
- Cola and other soft drinks, decaffeinated - 0 milligrams per 12 ounces
- Cocoa - 3 - 13 milligrams per cup
- Chocolate, milk - 3-6 milligrams per ounce
- Chocolate, bittersweet - 25 milligrams per ounce
How does caffeine affect the body?
Caffeine binds to the same receptors as adenosine.
Whether caffeine is consumed in food or as a medicine, it changes the way the brain and body work. Once consumed, caffeine is absorbed into the blood and body tissues within around 45 minutes.
Caffeine is molecularly similar to adenosine, a chemical that is present in all human cells.
In the brain, adenosine acts as a central nervous system depressant.
In normal conditions, adenosine promotes sleep and suppresses arousal by slowing down nerve activity. Adenosine binding also causes blood vessels in the brain to dilate, to increase oxygen intake during sleep.
When awake, the levels of adenosine in the brain rise each hour.
To a nerve cell, caffeine looks like adenosine. Caffeine binds to the adenosine receptors. However, in contrast to adenosine, it does not decrease the cell's activity. As caffeine utilizes all the receptors adenosine binds to, the cells can no longer sense adenosine. As a result, instead of slowing down because of the adenosine level, cellular activity speeds up.
Caffeine blocks adenosine's ability to open up the brain's blood vessels, causing them to constrict - this is the reason caffeine is used in pain relief medicine for headaches. If the headache is vascular, the effect of caffeine narrowing the blood vessels can offer relief.
With caffeine blocking adenosine, there is an increase in excitatory neurotransmitters in the brain. The pituitary gland observes the increased activity and releases hormones that tell the adrenal glands to produce epinephrine. Caffeine's main effect on the body is an increased temporary sense of wakefulness and alertness, but it can also cause issues such as:
- Jitters and shakes
- Disrupted sleep
- Fast or uneven heartbeat
- High blood pressure
- Headaches
- Nervousness
- Dizziness
- Dependency
- Dehydration
Once consumed, caffeine reaches peak level in the blood within 1 hour and remains there for 4-6 hours. Caffeine increases the release of acid in the stomach, sometimes leading to an upset stomach or heartburn.
Caffeine has been associated with increased urinary volume and frequency causing the body to lose water and electrolytes like potassium and sodium; however, studies show that caffeinated beverages in standard servings may not have a strong diuretic effect. There may be great variability in caffeine's diuretic property on different people.
Caffeine side effects
Heavy daily caffeine use - more than 500-600 milligrams a day - may cause side effects such as:
- Insomnia
- Nervousness
- Restlessness
- Irritability
- Stomach upset
- Diarrhea
- Dizziness
- Nausea
- Fast heartbeat
- Muscle tremors
Caffeine can interfere with the sleep cycle. Sleep loss is cumulative, and even small nightly decreases can add up and disturb daytime alertness and performance. The irony, of course, is that people often use caffeine as a way to improve alertness after a bad night's sleep.
Some medicines may interact with caffeine:
- Some antibiotics interfere with caffeine breakdown
- Theophylline: a bronchodilator - caffeine increases concentration of theophylline in blood
- Antiplatelet and anticoagulant drugs - aspirin, warfarin (Coumadin) and others - caffeine appears to have an antiplatelet effect, but this has not been confirmed in humans
- Beta-adrenergic agonists: ibuterol (Ventolin, Proventil) and isoproterenol (Isuprel) for instance - caffeine may increase the cardiac effects of these drugs
- Carbamazepine: caffeine reduces the bioavailability of this anti-seizure medication and could increase the risk of seizures
Caffeine is also thought to interact with other medications:
- Cimetidine (Tagamet)
- Clozapine (Clozaril)
- Dipyridamole (Persantine)
- Disulfiram (Antabuse)
- Diuretic drugs
- Estrogens
- Ethosuximide
- Felbamate
- Flutamide (Eulexin)
- Theophylline
- Valproate
A number of herbs and supplements can interact with caffeine to varying degrees; these include:
- Calcium
- Creatine: a combination of ephedra, caffeine, and creatine has been associated with ischemic stroke
- Danshen
- Echinacea
- Ephedra: can increase the risk of serious, life-threatening effects such as hypertension, heart attack, stroke, and seizures - avoid taking ephedra with caffeine
- Kudzu
- Melatonin
- Magnesium
- Red clover
Is caffeine addictive?
There has been much debate surrounding the question of whether caffeine is an addictive substance. In 2013, the American Psychiatric Association added caffeine withdrawal to the list of recognized conditions in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Not all caffeine consumers suffer withdrawal symptoms, though.
Symptoms begin about 12-24 hours after sudden cessation of caffeine consumption and reach a peak after 20-48 hours. A gradual reduction in consumption over a period of days does not result in these symptoms.
Research has shown that caffeine does not activate the pathways in the brain that are related to addiction and reward in opposition to other drugs. Therefore, researchers conclude that caffeine is not an addictive substance.
Caffeine health benefits
Caffeine can improve physical performance during endurance exercise.
Studies have shown caffeine to have potential health benefits; some of these are discussed below.
Weight loss
Caffeine may boost weight loss or prevent weight gain, although there is no conclusive evidence to determine long-term results. Possible theories of how caffeine might affect weight include:
- Appetite suppression: caffeine may temporarily reduce the desire to eat
- Calorie burning: caffeine may stimulate thermogenesis - one method your body uses to generate heat and energy from digesting food
Weight loss products that are marketed as thermogenics may contain caffeine and ephedra (ephedrine).
The European Food Safety Authority (EFSA) concluded that there is a link between a 75 milligram serving of caffeine and both increased attention and alertness.
Taking a 160-600 milligrams dose of caffeine can improve mental alertness, speed, reasoning, and memory when subjects are fatigued. However, while caffeine can help recover alertness, it is not comparable to getting sufficient sleep.
Caffeine does not sober up someone who is drunk, nor does it make them fit to drive - it does not get rid of the effects of alcohol.
Sports performance
Caffeine can improve physical performance during endurance exercise.
The EFSA recognizes that caffeine can increase endurance performance, endurance capacity, and reduction in perceived exertion.
The effects of caffeine on short-term, high-intensity exercise remain inconclusive.
Brain function
Caffeine works at adenosine receptors in the brain. Also, when caffeine is absorbed in the form of coffee, other compounds in coffee, such as polyphenol antioxidants, act on various pathways and may play an additional protective role.
Cognitive decline
Several studies suggest that regular, lifelong, moderate consumption of caffeine may slow down physiological, age-related cognitive decline, especially in women and those over 80 years old.
Alzheimer's and Parkinson's disease
Caffeine decreases the risk for age-related cognitive decline in diseases such as Alzheimer's and Parkinson's.
A systematic review and meta-analysis found a protective effect of lifelong caffeine consumption and the risk of developing Alzheimer's disease.
There are a wealth of epidemiological studies reporting an inverse association between coffee consumption and risk of Parkinson's disease.
Research from Johns Hopkins University suggests that a dose of caffeine after a learning session may help to boost long-term memory.
Liver and colon
Caffeine enemas may help prepare the colon for an endoscopy or colonoscopy by supporting the excretion of bile through the colon wall. Although proponents of coffee or caffeine enemas claim that this therapy increases the levels of glutathione (an antioxidant) and thereby supports the natural processes of detoxification in the liver, there is little evidence to support this theory.
There is evidence that coffee consumption is associated with decreased risk of cirrhosis and lower rate of disease progression in hepatitis C infection. Observational studies demonstrate a protective effect of coffee with regard to hepatocellular cancer.
Eyelid spasm
Caffeine may help protect people from an eye disorder known as blepharospasm, according to a study published in the Journal of Neurology, Neurosurgery, and Psychiatry. The condition, caused by abnormal brain function, makes people blink incessantly and can leave them functionally blind.
Researchers from the University of Maryland School of Medicine in Baltimore, MD, found that caffeine may be effective in protecting the lens against damage that could lead to the formation of cataracts.
Skin cancer
A Rutgers study strengthens the theory that caffeine guards against certain skin cancers. Based on studies in mice, scientists believe that caffeine applied directly to the skin might help prevent damaging ultraviolet light from causing skin cancer.
In another study, researchers found that drinking three cups of caffeinated coffee a day was linked to a 21 percent lower risk of developing basal cell carcinoma in women, and a 10 percent lower risk in men, compared with drinking less than one cup per month.
Kidney stones
A study of 217,883 participants analyzed the association between caffeine intake and the risk of developing kidney stones.
Participants with a higher intake of caffeine had a reduced risk of developing kidney stones.
Mouth and throat cancer
In a study of 968,432 men and women, participants who reported drinking more than 4 cups of coffee a day had a 49 percent lower risk of death from oral cancer compared with those who drank no coffee at all or only an occasional cup.
Scientists examining data collected in Sweden about 34,670 women without a history of cardiovascular disease found that women who drank more than one cup of coffee per day had a 22-25 percent lower risk of stroke compared with women who drank less.
They found that low or no coffee drinking was linked to an increased risk of stroke.
Type 2 diabetes
In an analysis of data from three large studies, covering a 20-year period, researchers noted that participants who increased their coffee intake by more than one cup a day over a 4-year period had an 1 percent lower risk of developing type 2 diabetes compared with people who did not change their intake.
In addition, people who lowered their daily consumption by more than one cup of coffee showed a 17 percent higher risk for type 2 diabetes.
Further claimed health benefits of caffeine include:
- Decreased risk of endometrial cancer
- Reduced risk of prostate cancer
- Protection against head and neck cancer
- Helping to prevent the return of breast cancer
What are the health risks of consuming caffeine?
While much of the research published does allude to the safety and even potential benefits of caffeine (in moderation), there are a handful of research studies that highlight the potentially harmful effects of caffeine.
There is no clear link between caffeine intake and depression. However, caffeine intake and depression may be linked indirectly among people who are particularly sensitive to the effects of caffeine or who consume too much caffeine.
Blood sugar
The effects of caffeine on blood glucose levels and insulin activity are highly variable among different people. There is some evidence that caffeine impairs insulin action but does not necessarily affect blood sugar (glucose) levels in young, healthy adults.
However, if you have type 2 diabetes, the impact of caffeine on insulin action may be associated with a small but detectable rise in blood sugar levels, particularly after meals.
Pregnant people are recommended to consume less than 300 milligrams of caffeine a day.
Studies in humans have shown that doses of caffeine greater than 300 milligrams (an amount equal to around three cups of coffee) a day may cause miscarriage or slow the growth of a developing fetus.
Also, use of large amounts of caffeine by the mother during pregnancy may cause problems with the heart rhythm of the fetus.
Those who are pregnant are recommended to limit caffeine to less than 200 milligrams a day.
Caffeine passes into breast milk in small amounts and may build up in the nursing baby.
Studies have shown that babies may appear jittery and have trouble sleeping when their mothers drink large amounts of caffeinated beverages.
Preliminary research suggests that an extra jolt or two of caffeine may trigger a gout attack in people with the condition.
Drinking six or more caffeinated beverages in 24 hours is associated with an almost four-fold increase in the risk of recurrent gout attacks.
In a study from the University of Alabama evaluating data on 1,356 women who reported taking in 329 milligrams of caffeine a day - about three cups of coffee or more - 70 percent had a higher likelihood of bladder problems.
Results from a study published in the Journal of Clinical Sleep Medicine showed that consuming caffeine 3 and even 6 hours before bedtime significantly disrupts sleep - even when consumed 6 hours before bedtime, it reduced objectively measured total sleep time by more than 1 hour.
A population-based study published in Neurology found that dietary and medicinal caffeine consumption appears to be a modest risk factor for chronic daily headache onset, regardless of headache type.
There is some research to suggest that caffeine reduces muscle activity in the fallopian tubes that carry eggs from the ovaries to the womb.
The authors of the study say that caffeine can reduce a woman's chances of becoming pregnant by about 27 percent.
A study published in the journal Menopause found that menopausal women who consumed caffeine had a greater degree of vasomotor symptoms including hot flashes and night sweats.
Dangers of mixing alcohol and energy drinks
Energy drinks are beverages that typically contain caffeine, other plant-based stimulants, simple sugars, and additives.
When alcoholic beverages are mixed with energy drinks, the caffeine can mask the depressant effects of alcohol. Alcohol also decreases the metabolism of caffeine, prolonging its effects.
Drinkers who consume alcohol mixed with energy drinks are three times more likely to binge drink than drinkers who do not report mixing alcohol with energy drinks. They are also twice as likely to report experiencing sexual assault, sexually assaulting someone else, riding with a driver who was under the influence of alcohol, being physically hurt or injured, and requiring medical treatment.
Ingesting massive doses of caffeine all at once should be avoided as it can cause numerous health problems.
Death by caffeine might sound unlikely, but it can and has happened.
The FDA knows of a 19-year-old college student who died after taking an overdose of caffeine tablets to stay awake. A caffeine tablet contains as much caffeine as one to three 5-ounce cups of coffee.3
A single teaspoon of pure caffeine is roughly equivalent to 25 cups of coffee. Pure caffeine is a powerful stimulant, and very small amounts may cause accidental overdose. Parents should be aware that these products might be attractive to young people.
The symptoms of a caffeine overdose include:
- Jitters, restlessness, and nervousness
- Increased heartbeat
- Nausea
- Anxiety
- Heart palpitations
- Insomnia
- Sweating
- Dizziness
- Vomiting
- Cardiac arrest
Studies suggest that moderate amounts of caffeine are not harmful. How much is moderate? One hundred to 200 milligrams (one to two 5-ounce cups of coffee) each day is the limit that some doctors suggest, but each person is different.
How caffeine affects people varies with their size, their sex, how sensitive they are to caffeine's effects, and any medications or supplements they may be taking. Experts agree that 600 milligrams (four to seven cups of coffee) of caffeine or more each day is too much.
The human body has evolved various mechanisms to reduce the likelihood of caffeine overdose by preventing excessive consumption. Well before reaching a toxic level of caffeine, a person would experience side effects such as nausea and vomiting that would prevent them from consuming additional caffeine.
Indeed, it would take 149 or so cans of caffeinated energy drink to kill an average adult male, meaning that vomiting would most certainly occur before a fatal overdose of caffeine.


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Protect your lips while giving them a sexy sheen. Try Neutrogena's Moisture Shine Lip Soother. It is SPF 20 giving more protection than average lip glosses and hydrates, soothes and protects dry lips on contact while keeping your lips beautiful with shine. This product has a unique hydragel formula contains cucumber, chamomile and glycerin for intense moisturization. You can find this product at your local Walgreens store.
Intensify the high shine of your lips with a beautiful teal-colored Rosita Multi-String Triange Bra Bikini from Nicolita. This aqua Rosita Bermuda triangle bra with multi string neck ties is adorned by gold beads giving a chic look. The beads are adjustable (are able to slide along the spaghetti) for a perfect fit! The bra is also lined with removable pads.
Comments will be approved before showing up.
The Parrot Black One Piece swimsuit is one swimsuit you cannot live without.
The SaveSaveSaveSave
Hola! I'm Nicolita owner & designer Nicole Di Rocco. In this video I'll show you why and how we created our signature Nicolita Bottom fit.
Nicolita has one-of-kind swimwear styles that are carefully designed to flatter your figure. Say goodbye to those ill-fitting bikini bottoms and say hello to comfort and fit!
Below are a few of our most popular styles that were designed with YOUR hips in mind.
I want to help you find the Perfect Fit Nicolita Style. Below I have created a Nicolita Swimwear Fit guide to match your curves with our swimwear options and styles. If you still have questions of which bikini or one piece style would look best with your body shape just Call 866-NICOLITA (866-642-6548) Email hola@mynicolita, or Skype me @mynicolita.
Over the last 13 years since I started Nicolita in 2003, I have worked with a lot of Nicolita clients on selecting the perfect swimsuit for them. I'm the first to admit that wearing a bikini or one piece swimsuit can be challenging for the majority of us. Even if you have a rockin' body, there are certain styles that work better on certain body shapes.
But I am a strong believer that there is the perfect swimsuit out there for you. And we have gone ahead and picked out some styles that are flattering for you!
Women with larger cup sizes are primarily looking for 2 things when trying on swimwear: coverage and support. While going up a size in the top can provide more coverage, some styles just won't provide the coverage and support you may be looking for. Look for styles with side boning and molded cups to give you the support and coverage you desire, without the pinching of an underwire!For support and coverage, check out:
Have a smaller bust and want to create the illusion of a bigger chest? Styles with details like ruffles and molded cups will add volume and create cleavage!
For adding volume to a smaller chest, check out:
Haute Dot Bow Tie Bikini Tube Top
If you're looking to tone down the appearance of broad shoulders, look for one-shoulder and detailed tops which will draw attention away from wide set shoulders. Deep V necklines will keep the attention focused on your chest and the low cut back will make your shoulders appear more narrow.
To elongate the torso, check out:
Rumba Ruffles One Shoulder Top
Looking to add more curve to that backside? Look for bottoms with backside details like ruffles, shirring, or our signature knotty bottom. These details add more curve to your bottom and create a more shapely bum.
To add curves to a not so curvy bottom, check out:
We all have those days we would rather cover our midsection. To conceal your midriff while flattering your other assets, look for styles that have shirring throughout the midsection to camouflage any insecurities.
For tummy control, check out:
Deep V One Piece With Shirring
Noche Cha Cha High-Waisted Bottoms
Trying to keep your skin out of the sun, or just desire to be more covered? Look for styles that provide more coverage without sacrificing style, like high-neck tops, high-waist bottoms, and one pieces!
For more coverage, check out:


text: It mightn't be high summer, and you're unlikely sunbaking, swimming or swanning about on a boat. But lo and behold, the sun shines on! Protect your peepers and prep for the imminent spring rays (just a few days now!) with this tasty haul of face candy. The best part? It's all on sale — so a pat on the back for you, thrifty.


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Huge office space is available for sale at the Tower 1 of Boulevard Plaza in Downtown, Dubai. This office is a shell and core type with an area measure of 4,500 square feet which can be designed ... More details ›
Marketed by Partner Network, Dubai First Homes.


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Photos are for members only!!
Peachmate is a 100% free sex site for adults looking for fun with no strings attached.
Escort ads, casual sex groups, personal ads, video chat and much more.
I'm Me I suppose. Interested in seeing how this works and seeing who finds me sexy mostly.


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Ground Turkey and Rice Soup
Recipe by Kana6615
A soup recipe that pleased even my children!
Top Review by Canadian WesternGirl
This soup was pretty good, but not quite 5 star for me. I was afraid that the ground turkey would be a bit bland, so I sprinkled a bit of extra tumeric and savory onto the meat as I was frying it. I also added a bit more sea salt as I went along - I wasn't sure how much I should use originally, since the recipe wasn't very specific.
Overall, it's a pretty tasty soup and I like the brown rice and ground turkey as healthy ingredients.
See Discussion:2 Reviews
Ingredients Nutrition
- 1 tablespoon sunflower oil
- 1 lb ground turkey
- 1⁄2 cup onion, chopped
- 3⁄4 cup celery rib, chopped
- 1 cup brown rice
- 7 cups chicken broth
- 1 teaspoon savory
- 1⁄2 teaspoon turmeric
- 1⁄2 teaspoon coriander
- salt and pepper
Directions See How It's Made
- Put oil in large pot. Saute onions and celery.
- Add chicken broth, spices and rice. Cover and cook 1 hour over medium flame.
- Meanwhile, brown turkey meat and add to the soup mixture.
- Season with salt and pepper.


text: PoliticsObstacles line Colombia's peace route Government team continues negotiations with the FARC rebel group in Cuba despite major sticking points. 10 Sep 2013 18:57 GMT | Politics, Latin America, Colombia, Cuba Members of a Colombian negotiating team are continuing to hold peace talks with the FARC rebel group in Cuba. But there are still major sticking points before an agreement can be reached. Al Jazeera's Teresa Bo reports from Havana.Source: Al Jazeera


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This is junior Izzy McMullen's second year writing for The Pitch. She is the Online Feature Editor for The Pitch Online. Izzy took the Journalism 1 class freshman year and enjoyed it very much. She was a Online Co-Assistant Feature Section Editor last year and enjoyed it as well. In her free time she enjoys hanging out with friends and playing lacrosse for WJ, along with her club lacrosse team. She is also a member of the P.R.O.V.I.D.E club and the coding club. She hopes to continue on The Pitch up through senior year. [email protected]
This doesn't go for just conservatives. I have been discriminated…


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CHINA: BASF begins trial operations at mononitrobenzene plant in Chongqing
BASF has begun trial operations at the mononitrobenzene plant within the integrated 400,000 metric tonne methylene diphenyl diisocyanate (MDI) complex in Chongqing, China. Mononitrobenzene is a precursor for the production of MDI.
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Despite what the title suggests, this blog isn't about video game addiction or anything like that. I've been thinking about the trouble that people have when it comes to advancing in games. I'm guessing that all gamers have experienced the seemingly universal problem of not being able to get past a certain point in a game. You come up with all sorts of different ideas as to what can be done and no matter what you try, the solution doesn't present itself. It could be a boss that you hit with everything that you have only to see them standing once the smoke clears or a puzzle that you can't figure out. Maybe it only takes you a matter of minutes before you become frustrated with it or possibly you keep at it for hours or days before you finally decide to turn to other means for help.
It could just be me, but I like finding my own way through games. It's probably because I think that I should be able to figure a way out of whatever situation a video game throws at me. If I do decide to get help, it adds insult to injury when it turns out the answer is something simple or very obvious. However, it really annoys me when I have to look for tips and tactics in order to get through something in a game. Usually once I do decide to go down the dark path, I start to get into the habit of it. If I get stuck at another part, I just look to see what I need to do usually without much hesitation. That could be a result of laziness or just knowing that I already needed help for the game so why not just continue on and use someone else's strategy to get past any future obstacles.
Some gamers buy a strategy guide when they think a game is going to be difficult. These guides sometimes come in snazzy collector's editions, while others are just the standard knowledge bomb edition.
I would guess that most gamers opt for using the Internet in order to find the answers that they so desire. Of course you can run into a problem if the game that you are struggling with is a new one especially if it isn't too popular because there may not be a lot of assistance available. In that case, a strategy guide may be necessary or the person might have to just wait it out.
This idea of how much are you willing to put up with from a video game before you decide to seek help is something that I've always wondered when it comes to other people. Since there is a wide spectrum of gamers, I can see some of them refusing any form of help constantly banging their heads against the proverbial wall until they find a solution, luck out, or give up. Whereas others probably don't have any patience and after one or two tries just give up or try to find the answer using resources that are available to them. I'm guessing however that most people stay at it for awhile and then whenever they get tired of it, call mercy and try to find the answer somewhere else. In the end, everyone threshold level is different. But it is very interesting to see how others deals with the problems that they struggle mightily with when they encounter them in video games.


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Our countdown of the Pac-12's top 25 preseason players in 2013 continues.
A lot of good players, as it happens every year, won't make the preseason list. It is in their hands to make the postseason list.
You can review our 2012 postseason top 25 here.
9. David Yankey, OG, Stanford
2012 numbers: Yankey helped pave the way for Stepfan Taylor's 1,530 rushing yards -- which was the second highest total in school history. He was part of a unit that allowed a league-low 17 sacks during the regular season and 20 in 14 games and he yielded just one sack in 14 games.
2012 postseason ranking: No. 19
Making the case for Yankey: Though his natural position is guard, he started 13 games last season at left tackle. However, at times during the year, he ended up playing four of the five spots on the line and even pitched in at tight end in some of Stanford's overloaded formations. Playing out of position, Yankey was a consensus All-American, first-team all-conference and he earned the league's Morris Trophy for top offensive lineman. The 6-5, 313-pounder from Georgia returns this year to his natural position inside where he's considered one of the top pulling linemen in the nation. He headlines a Stanford offensive front that is regarded by many as tops in the country and will again be a key player in the Cardinal's rushing attack as they return to a by-committee approach following the departure of Taylor.
10. Scott Crichton, DE, Oregon State
11. Ed Reynolds, S, Stanford
12. Taylor Kelly, QB, Arizona State
13. Austin Seferian Jenkins, TE, Washington
14. De'Anthony Thomas, RB, Oregon
15. Bishop Sankey, RB, Washington
16. Shayne Skov, LB, Stanford
17. Kevin Hogan, QB, Stanford
18. Xavier Su'a-Filo, OL, UCLA
19. Morgan Breslin, OLB, USC
20. Colt Lyerla, TE, Oregon
21. Carl Bradford, LB, Arizona State
22. Brandin Cooks, WR, Oregon State
23. Hroniss Grasu, C, Oregon
24. Marion Grice, RB, Arizona State
25. Ben Gardner, DE, Stanford


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The Masters 2014: Butch Harmon reacts to Tiger Woods pulling out of Augusta
Last Updated: 03/04/14 4:44pm
Butch Harmon admits it will be strange working on The Masters without having Tiger Woods in the field - after his former coaching pupil pulled out of this year's Augusta event.
Woods has been struggling with back spasms of late, and was forced to have surgery on a pinched nerve which rules him out of Augusta for the first time since 1995.
Harmon will find it strange not seeing Woods prowling around Augusta National when he takes his place as part of the Sky Sports commentary team, but it will also be a blow for the fans and the tournament itself.
"Since Tiger's record win in 1997 he has been a major part of the Masters at Augusta National," Harmon told Sky Sports News. "It's going to be strange to see a Masters contended without Tiger there.
"There's no doubt about it, it's a blow for all golf fans. We do the Masters on Sky and Tiger's a huge part of the coverage at all times so it's going to be very unusual to see a Masters without Tiger Woods.
"Having said that, the Masters is the Masters and it'll survive beautifully, but I think all of us who have followed Tiger Woods through his whole career know how much he loves Augusta National, he's won four times there and it's a course he feels comfortable on.
"And obviously he's not happy that he has to miss it but once again if he's made the decision to have surgery obviously it was needed and hopefully he comes back stronger after he rehabs."
Woods is never one to let injury stand in his way, so Harmon believes the surgery must have been necessary for him to continue his career.
"I think Tiger is looking at the longevity of his career and, if he tried to play, he could injure his back further. In the long-run, if this makes him healthier, then we'll see a stronger and better Tiger Woods come back when he is able. He hasn't won a major since the 2008 US Open and people will look at this injury as a (further) setback.
Positive step
"But I think for Tiger, it's a positive step. He's had some problems with his back, he is dealing with it so he can come back and give 100 per cent effort when he is healthy."
I think Tiger is looking at the longevity of his career and, if he tried to play, he could injure his back further. In the long-run, if this makes him healthier, then we'll see a stronger and better Tiger Woods .
Butch Harmon
Harmon says players will react differently to not having Woods around for a while, and it will also be interesting to see how he responds when he returns.
"They'll have two schools of thought - obviously when you win a tournament you want to beat the best and Tiger Woods is the No 1 player in the world and has been forever.
"Then the other school of thought will be well, Tiger's not here so that gives us a better chance to win.
"But the bottom line is that we're all going to have to wait and see when he does come back. Knowing Tiger, he's chosen to have this surgery so he won't come back until he's ready and it'll be interesting to see how it goes from there."
Watch all four days of the Masters live on Sky Sports 4HD from 7pm on Thursday, April 10


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Bangaram in India awaits visitors! Discover the attractions, activities and accommodation in Bangaram. The nearest major city to Bangaram is Puducherry. Add Puducherry to your vacation plan, it has an interesting bunch of activities to do on your visit like Paradise Beach, Promenade, The Sacred Heart Of Jesus Church. Most online packages to this city are of 1-2 days.
Yes,it is that simple really! Enjoy your trip! Keep travelling!
Explore the best travel planner for your visit to Bangaram and create a flawless plan in few simple steps!


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Mash & Onion Muffins
Recipe by Sonya01
You could use potato, kumara/sweet potato or butternut pumpkin for these or a combination would be nice too.
Top Review by Lalaloula
Just WOW!!! These muffins are amazing! They have a lovely taste and a great texture, too. The spring onion and dill add an extra flavour which goes great with the mash (I chose to use pumpkin). The interior of these is fluffy and moist and melts in your mouth. I made half the recipe and ended up with 6 ordinary sized muffins. THANKS SO MUCH for sharing these tasty treats with us, Sonya! Ill surely make them again and I cant wait to try out the other mash variations. Made and reviewed for Everyday Is A Holiday Tag Game August 09.
See Discussion:1 Review
Ingredients Nutrition
- 1 cup mashed cooked potato, at room temperature (2 medium)
- 2 eggs
- 60 g butter, melted
- 1 1⁄2 cups buttermilk (or use soured milk)
- 3 green onions, finely chopped
- 2 tablespoons chopped dill
- 2 cups self-raising flour
Directions See How It's Made
- Preheat oven to 180°C/160°C fan forced.
- Lightly grease a 6-hole Texas muffin tray.
- Place potato, eggs and butter in a mixing bowl. Gradually add milk and mix, using a fork to break up lumps, until combined. Season with salt and black pepper. Stir in onion and dill. Stir in flour until just moistened (do not overmix). Spoon into prepared tray, filling almost full.
- Bake for 30-35 minutes or until muffins are cooked when tested with a skewer.
- Serve warm.


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Optic Rib Flat Tall in Blue Multi with Violet
Art Glass Vessel
Created by Michael Trimpol and Monique LaJeunesse
Kaleidoscopic swirls of color dance across the surface of this vibrant blown glass vessel. Flattened profile fits well in narrow spaces. Each piece is unique and will vary.
Shipping Information
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Little River HotGlass StudioOptic Rib Flat Tall in Blue Multi with Violet, Small
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Comments about Optic Rib Flat Tall in Blue Multi with Violet, Small:
The colors are stunning!
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text:
Post Market Quality Assurance is responsible for quality complaints for all Medical Device products distributed by Fresenius Kabi
Mission StatementTo exceed customer satisfaction by treating our customers with respect and to understand their needs in order to fully address their concerns in a knowledgeable, effective, and timely manner.
Services PMQA Provides:
Phone: 800-933-6925Email: firstname.lastname@example.com: 888-858-2983
Fresenius Kabi is committed to quality in everything we do. If you need to report a product quality issue, please submit a report to Post Market Quality Assurance (PMQA).
Important: If reaction or injury has occurred, or you need additional assistance, call Fresenius Kabi Post Market Quality Assurance (PMQA) immediately at 1-800-933-6925.
Please complete the appropriate form below and submit to Post Market Quality Assurance (PMQA).
To learn more about submitting a performance report online, please click the following link How to Submit a Report
Please note: To submit a report online, you will need to request a User ID.
To request access and/or submit a report online, please click the following linkOnline Product Performance Report Site
Click Here


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What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
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Text becomes hidden when selecting a productAsked by Valshe001 on October 26, 2015 at 10:51 AMHi
Is it possible you can review the pay-page, when an item is selected all
other features blank out, the customer has to click elsewhere on the form
to bring the features back into view, but even that is not guaranteed to
make all visible, honestly it is soooo annoying.
- Basically you complete the form
- Select next or buy now
- You have a list of product to buy with check boxes
- You select one box and all the others blank out, thus not visible at
- Click elsewhere in the form and the options reappear
Some customers have left the form altogether thinking it some kind of scam,
i have attached a JPEG of what is visible (or not) when option selected.
Note happens on all our pages where we have selected the Pet Lover as our
JotForm Support
That seems a style issue on that particular theme you are using.
Please inject this CSS codes to your form, this should correct it.
.hover-product-item:hover {
color: #fff;
Guide: https://www.jotform.com/help/117-How-to-Inject-Custom-CSS-Codes-to-your-Form (paste this code at the bottom part)


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BKD promotes Turnage - Mississippi Business Journal
Edward W. "Trey" Turnage, CPA, has been promoted to senior manager of BKD, LLP's Jackson and Oxford offices, Turnage, a member of BKD's National Financial Services Group, performs audit and consulting services for public and private financial institutions. He also provides audit services for manufacturing and not-for-profit organizations. Turnage has more than 10 years of ...
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Swirly Girly Address Labels (4 designs)
Jewel-tone colors highlight all your mailings! 4-design set of address labels saves time addressing letters and packages and identify your belongings to avoid mix-ups. Self-adhesive; 1 1/8" x 2 1/4".
- Set of 144
Specify block or script
Specify up to 4 lines, up to 26 characters and spaces each
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