text:
Study on the Incidence of Delirium in a Respiratory Weaning Centre (delricu)
Recruitment status was: Recruiting
- Full Text View
- Tabular View
- No Study Results Posted
- Disclaimer
- How to Read a Study Record
|Study Type:
|Study Design:
|Observational Model: Cohort
Time Perspective: Prospective
|Official Title:
|Delirium in Patients Admitted to a Respiratory Weaning Centre: Analysis of Incidence and Risk Factor
|Estimated Enrollment:
|Study Start Date:
|January 2007
|Estimated Study Completion Date:
|March 2008
|Estimated Primary Completion Date:
|February 2008 (Final data collection date for primary outcome measure)
Detailed Description:
Delirium has been defined, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), as a disturbance of consciousness characterized by an acute onset and fluctuating course. This impairment of cognitive functions, not being accounted for by a pre-existing dementia, reduces the patient's ability to receive, process and recall informations and its main features are inattention, disorganized thinking and reduced clarity of awareness of the environment.
All patients transferred from an intensive care unit to our respiratory weaning centre (RWC) will be screened for the occurrence of delirium. Our RWC is a 7-bed unit located within the respiratory department of a rehabilitation hospital and is fully equipped for invasive and non-invasive mechanical ventilation (MV) and for invasive and noninvasive cardiorespiratory monitoring. Patients are generally transferred to our unit from a general or surgical ICU for weaning from MV or, in case of patients already weaned, for rehabilitation, monitoring and intensive nursing care. All patients or their next of kin will give written informed consent to participate to the study and the study protocol has been approved by the local ethics committee.
For the assessment of delirium we use the Intensive Care Delirium Screening Checklist (ICDSC),a diagnostic tool already validated in the intensive care setting even in mechanically ventilated patients. It is based on the assessment of 8 different items dealing with the patient's mental status: each one is scored 0 or 1 in case of, respectively, absence or presence of the item itself and the final score is the resultant of the sum of the different items (see the appendix 1 for further details). The evaluation is performed on a daily basis by the physician in charge and the ICDSC score is ranked in the following way: 0 to 1 is considered normal, 2 to 3 is considered borderline, (i.e. indicative of a subsyndromal delirious state) and 4 or greater is considered diagnostic for delirium (13). In presence of a score greater than 1 the psychiatrist is called for consultation and diagnostic confirmation. Upon discharge of the patient from our RWC a score trend is drawn for every patient using the three highest scores sampled during the phases of admission, of mid stay and of discharge. Cases of overt delirium (only patients with ICDSC score ≥4) are categorized as hyperactive or hypoactive, according to a currently accepted classification. Treatment of delirium, when properly diagnosed, is instituted according to the psychiatist's prescriptions.
Patient's data collection include demographic data (age, gender), severity score (SAPS II), reason for admission (i.e. need for mechanical ventilation (MV) or not (NMV)) and previous episodes of delirium (hyperactive forms) occurring during ICU stay not linked to a pre-existing mental disease or to an acquired brain failure of vascular, metabolic or infectious origin. The Kelly scale is used for the assessment of the level of consciousness: the patient is considered comatose in presence of a persistent (>24 hours) Kelly score of ≥4. As far as the use of sedatives and analgesics in our RWC is concerned, our policy is based on the avoidance of continuous infusions regimens and on the limitation to the use of those drugs with a known or suspected capability to induce delirium; each drug is prescribed when strictly needed according to the judgement of the physician on duty and is targeted to the treatment of the specific symptom: pain, anxiety, insomnia etc.
Analysis of variance for repeated measures (MANOVA) is employed for statistical analysis, and a p value lower than 0.05 is considered the threshold value for statistical significance.
|Ages Eligible for Study:
|20 Years to 80 Years (Adult, Senior)
|Sexes Eligible for Study:
|Accepts Healthy Volunteers:
|Sampling Method:
|Non-Probability Sample
Inclusion Criteria:
- All patients admitted in the respiratory weaning centre
Exclusion Criteria:
- Patients in deep coma
- Deceased or transferred to another ward within 72 hours of admission
Please refer to this study by its ClinicalTrials.gov identifier: NCT00611377
|Department of respiratory medicine and intensive care unit
|Pavia, PV, Italy, 27100
|Contact: Piero M Ceriana, MD 39 0382592 ext 804 firstname.lastname@example.com
|Principal Investigator: Piero M Ceriana, MD
|Principal Investigator:
|Piero M Ceriana
|Fondazione Salvatore Maugeri
|Responsible Party:
|Piero Ceriana, Fondazione Salvatore Maugeri
|ClinicalTrials.gov Identifier:
|NCT00611377 History of Changes
|Other Study ID Numbers:
delirium in rwc
|Study First Received:
|January 28, 2008
|Last Updated:
|January 28, 2008
Keywords provided by Fondazione Salvatore Maugeri:
mechanical ventilation
severity score
Additional relevant MeSH terms:
Neurobehavioral Manifestations
Neurologic Manifestations
Nervous System Diseases
Signs and Symptoms
Neurocognitive Disorders
Mental Disorders
ClinicalTrials.gov processed this record on September 21, 2017


text:
Groene at the Legislature: Teacher absences, substitutes
Mail: Southern statues symbolize suppression
More opinion
Senate: Vote no on Graham-Cassidy health care plan
Fall: Good time to spray musk thistle in rosette stage
More Ag News
Three Maxwell school officials were cited Tuesday for failure to report alleged child abuse among 2-4 members of the 2011 wrestling team.
One assault allegedly occurred at a wrestling camp in the summer of 2011, attended by four Maxwell students. One student was allegedly sodomized by one Maxwell student with a pop bottle while he was held down by the other two.
The adults were at a coaches' meeting at the time, the alleged victim told a State Patrol investigator.
When the coach learned about it, he told the boys to quit jacking around and that that stuff needed to be stopped, the alleged victim told investigators.
Several months later, the same student was allegedly assaulted when another Maxwell student grabbed his penis on a school bus, according to the investigator's request for a search warrant.
At that time, the adults were at the front of the bus and didn't see it happen, the alleged victim told state investigators.
School officials investigated, but at least one parent was not satisified, and in April, the Nebraska State Patrol in conjunction with the Lincoln County Attorneys Office and the State Health and Human Services Department picked up the investigation.
When the school investigated, Boucher questioned some of the students about the bus incident and took statements, which he voluntarily gave later to state patrol investigators, according to the request for search warrant.
Boucher said he didn't think the allegations had merit, according to the State Patrol investigator. At one point, Twarling also told the State Patrol that the school investigators determined that the allegations were unfounded.
But the woman told the State Patrol that she saw a video of the assault at the wrestling camp.
On July 30, a Lincoln County judge authorized investigators to search pertinent files from the school, including the personnel files of as many as nine Maxwell school officials.
According to the State Patrol, the initial investigation led to several more potential alleged sexual assault victims, but the Patrol did not say that anyone has been charged with assault.
The investigation remains very active, Lt. Lynn Williams of the State Patrol office in North Platte said Tuesday in a prepared statement. There is potential for more victims and additional arrests or citations.
The three Maxwell school officials were cited with failure "to make a report of child abuse or neglect" to law enforcement or to the Nebraska Health and Human Services department, the State Patrol said.
Failure to do so is a misdemeanor punishable by a maximum of three months in jail and a $500 fine.
Anyone with information that might aid in the investigation is asked to contact the Troop D Headquarters at 308-535-8047.
Flatrock Publishing, Inc.
1300 E 4th St., Suite F
North Platte, NE 69101

subset: commoncrawl


text:
DAYTONA BEACH, Fla. - Daytona Beach Police Chief Michael Chitwood is back to work, recovering at the police department.
Chitwood described on Tuesday how he was attacked during Bike Week.
He said it's hard to do certain things with his left hand in a cast, but he's grateful he still has his right index finger.
"I could have swore he was gonna bite it off, and I didn't want to go through my life being known as the police chief who lost his finger on main street," said Chitwood.
Chitwood said he was walking up and down Main Street during Bike Week, when Michael Dangelo, 43, approached him, saying he could kill police officers.
Chitwood says he started to walk away.
"I was walking away. I figured he's drunk, he's high, I'm just gonna walk away from this guy," said Chitwood. "Why make an issue out of it?"
It was then that Dangelo spit on the chief's back. When Chitwood tried to arrest him, a fight broke out.
"I don't know what he's saying. All I know is I got to get my finger out of his mouth, because I think my finger is coming off, that's how hard he was biting and it seemed that the harder I hit him, the more commands I gave him, the harder he was not going to let go," he said.
Chitwood broke his hand in four places, has stitches in his head, and a bite mark on his right index finger.
"There were an awful lot of people who came to my aid," said Chitwood. "They didn't come to my aid because I was a police chief. They came to my aid because I was a cop who was trying to do the right thing, and they jumped in there, and made sure I didn't lose my finger."
Chitwood says he is still waiting for test results from that bite.
Dangelo was booked into the Volusia County Jail for assault on a law enforcement officer, resisting arrest and disorderly conduct.
As of Tuesday afternoon, Dangelo had not posted his $10,500 bond.
Chitwood says this year's Bike Week was the most violent against Daytona Beach Police Department officers, with four other incidents where officers were hurt.
In one case, an officer injured his elbow. In another, a Sergeant broke his leg while making an arrest.
Copyright 2013 by ClickOrlando.com. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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South Sydney see off Raiders in NRL semifinal
South Sydney are one step away from a first grand final appearance in 41 years after brushing aside Canberra 38-16 in Saturday's NRL semifinal at ANZ Stadium.
Rookie halfback Adam Reynolds was the star of the show for the Rabbitohs, scoring a try and kicking seven goals on his way to becoming only the second player in the club's history to chalk up more than 200 points in a season.
Eric Simms was the last player to record that feat in 1970 - the year the Rabbitohs won the 19th of their 20 premierships - and they must now beat Canterbury next Saturday if they are to add to that tally.
The win was Souths' first finals victory in 25 years.
Tries from Reynolds, Andrew Everingham and Sam Burgess helped the home side into a 20-10 advantage at halftime, but despite being on the back foot for the majority of the opening stanza, tries from Sam Williams and Sandor Earl, just before the break, gave the Raiders some hope.
The second half started in a similar fashion, with Reynolds, criticised for his quiet performance in the loss the Melbourne last week, continuing to shine.
Despite being under pressure from two Raiders players, the 23-year-old somehow threaded a grubber towards the end-goal area that deceived Josh Dugan, and Dylan Farrell pounced to score.
Michael Maguire's side looked in full control, but a risky no-look pass from back-rower Dave Taylor was punished when the Raiders won possession, floated the ball out wide towards Reece Robinson, and the winger scored his 17th try in an impressive debut season.
Dugan's conversion closed the gap to 10 points once again, but Souths continued to press in attack.
John Sutton was held up just short of the line on the hour-mark, only for Shaun Berrigan to be punished for the Raiders for not being square of the marker.
Reynolds kicked the penalty and four minutes later the game was iced when a penalty try was awarded to the hosts after Greg Inglis was hauled back by Blake Ferguson without the ball.
And 10 minutes from time Reynolds produced a perfectly-weighted kick to the right corner after Inglis made a 50-metre break, to turn defence into attack, and Everingham did well to get the ball down and score.
Fairfax Media


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Firenze Osteria
A stone's throw from Universal Studios, Firenze Osteria is setting the standard for Italian cuisine in Los Angeles. Chef Fabio Viviani, Fan Favorite on Top Chef Season 5, brings 500 year old recipes from Florence to Los Angeles.
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Reservations are suggested and accepted up to 30 days in advance. Please call 818-760-7081 or to find a table online please select below.Find a Table


text:
Royal Purple Oil Filter 20mm x 1.5 thread pitch
Product Details
Royal Purple Oil Filter features 100 percentage synthetic micro-glass media for superior particle removal with 99 percentage filtration efficiency at 25 microns. This product is designed with a high-performance silicone anti-drain back valve that prevents dry starts, even in extreme conditions and an extra heavy-duty rubber base gasket that ensures a leak-free seal. The Royal Purple Oil Filter also provides an ultra-strength filter housing that can endure higher burst strength than conventional filters. Royal Purple filters are fully compatible with all synthetic and conventional oils, provide superior particle removal, high-performance, optimized flow characteristics for maximum performance, and longer filter life.
Images used may be generic. Actual product may vary.
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Choosing a platform and a cloud model is an important decision for your business. While the public cloud is a powerful technology, it's not always the best fit for every workload. That's where the hybrid cloud comes in.
When working in concert with a properly deployed, purpose-built database architecture like MongoDB, a hybrid cloud infrastructure can help boost your business' performance. MongoDB is seeing widespread adoption by developers because it removes the barrier of maintaining complex systems and instead allows developers to focus on areas where their skills are most needed
But what does the hybrid cloud mean at Rackspace and in the broader hosting industry? That's the question our tech experts tackled last week in a webinar on the Rackspace Hybrid Cloud, ObjectRocket MongoDB and scalable SaaS applications.
The panelists included:
- Chris Lalonde, Co-Founder of ObjectRocket and Senior Director of Product at Rackspace
- John Engates, Chief Technology Officer at Rackspace
With a hybrid solution, you can get the security, privacy and control of dedicated bare metal servers along with the reliability of the public cloud. To optimize your business's performance, it makes sense to bring all of these capabilities together under one roof.
One company that took advantage of a hybrid cloud infrastructure is HubSpot, which moved part of its workload from Rackspace to Amazon Web Services several years ago. Using the AWS public cloud became more expensive than HubSpot anticipated because it was constantly overprovisioning and spending tons of engineering time on making up for the inherent limitations of the public cloud. Since moving its workload to the Rackspace Hybrid Cloud, HubSpot has experienced four times the efficiency. HubSpot's developers are happier and have access to more customized cloud platforms and leading edge software development practices like continuous integration and deployment.
At Rackspace, we want to combine the different components of the public cloud, private cloud and bare metal dedicated servers to maximize performance and place your applications where they run best. Check out the video of our webinar below to learn why more and more customers are turning to the hybrid cloud.


text: Sunday Is Frunday! Post Updated. Patch Released. See Below! You asked, begged, and pleaded with me. So here it is. Finally....Frunisher 1.0. Code (Text): /* * Your warranty is now void. * * Neither Trident, GetItNowMarketing, Savoxis, I, nor anyone else * are responsible for bricked devices, dead SD cards, * thermonuclear war, global warming, your GPS failing, spilling * coffee on your work shirt, car problems, technical difficulties, or * you getting fired because the alarm app failed. * * YOU are choosing to make these modifications, and if you point the * finger at me, or anyone else for messing up your device, I will * point and laugh at you for your own damn stupidity. * * UNDERSTOOD? Good. Now please scroll down


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Sep 05, 2012
Using Consumer Insights: 5 Key Tips from Kraft
400 million emails, 90 million site visits, 6 million video views, 1.1 billion advertising impressions, 1 billion recipes viewed … and a food magazine with more than a million paid subscribers that's on par with the Food Network's magazine, and is bigger than Food & Wine.
Kraft is a scale publishing platform, according to Julie Fleischer, director of CRM Content Strategy for Kraft Foods. So what can the rest of us learn from Kraft's enormous content marketing and social CRM programs, even if our own brands don't have the scope, reach and depth of content that Kraft has developed? As it turns out, a lot.
" We have an audience that is coming for our food solutions, staying longer than they do on other sites, and are likely to click through to more information," noted Julie.
Kraft has developed an engaged audience that they don't need to go find – the audience willingly comes back. Kraft's magazine, Food & Family, has a million subscribers – more than Food & Wine. As Julie noted, "People pay Kraft to receive our ads."
Kraft's content marketing brief: Create delicious meal solutions that inspire amazing food stories which spread to drive sales and create value for Kraft Foods.
This brief offers a few lessons. It's clearly focused on driving an outcome (getting people to make the recipes), with an eye toward encouraging user generated content, with the ultimate goal of moving the needle on sales
Content marketers, Julie noted, need to know how the consumers' minds work, as well as their habits and their rituals. Then you need to intercept them at those moments of need. An example, in January, themes include:
- Healthy eating
- Slow cooker recipes
- Bowl game recipes
- Black eyed pea recipes (during first week. It's a ritual)
But there's more to developing an editorial approach than customer rituals. Kraft takes a comprehensive approach. Here's a look at a sample of their editorial calendar:
As you can see, the calendar blends events, trends, rituals and a lot of customer and search data. Julie noted that Kraft is constantly updating, testing and tweaking the calendar. In particular, she noted the need to be spontaneous. Retain flexibility that lets you take advantage when you see something is working, and see how far you can make it run. An example she gave is illustrated at the top of this post. Kraft published a recipe for a cookie bar on Facebook, and when it took off, they recognized that, highlighting it on Pinterest and in the magazine, which triggered a fresh round of viral sharing and visibility for the recipe.
The top tips from Kraft for developing a content strategy that works:
- Add value to your consumer's life.
- Be captivating. You have to be as interesting and compelling as all other media out there if you want anyone to pay attention to you.
- Location. Be where you consumer is, where she goes. Be easy to find. Don't require people to come to you, go to them.
- Timeliness matters. Develop processes that get you to real time. Use nimble distribution methods. Adjust on the fly. Be of the moment.
- Measure. Engagement, return rates, satisfaction, virality.
Julie wrapped up by reminding us that consumer relationship marketing is about a value exchange. You give each other value.
Author Sarah Skerik (@sarahskerik525252) is PR Newswire's vice president of social media.
At PR Newswire, content marketing is powered by an agile communications approach – built on effectively listening to online conversations, targeting of active influencers, creating content based on the insights gleaned and syndicating content that is relevant, compelling and trustworthy on an ongoing basis to drive visibility and deliver results.
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Android Users - Coming Soon! - Migrating from aCar 4.8 to 5.0
Real Name: abd halim mohd amin Joined: June 2016
No vehicles yet.
Run the Air-con instead of applying brakes
Air conditioning puts a big load on the engine and can be se... ...
by Charles1989
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© 2017 Fuelly.com - All Rights Reserved. Sep 26, 2017 5:17 PM CDT
A simple & effecive way to track fuel consumption
Easy to understand the real cost of your vehicle


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Funtastic Boy Cologne
By Benetton for Men
Funtastic Boy Cologne by Benetton, Launched by the design house of benetton in 2000, funtastic boy is classified as a refreshing, fruity fragrance . This masculine scent possesses a blend of citrus, youthful and fresh notes. It is recommended for casual wear. All products are original, authentic name brands. We do not sell knockoffs or imitations. ... Read More
- Warner Bros
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- Watt Black
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- Weekend
- Weil
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- Weruska & Joel
- What About Adam
- Wild
- Wild Citrus
- Wild Essence
- Wild Spice
- Wild Woods
- Wile E Coyote
- Wilshire
- Wings
- Wise Essence
- Witness
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- Worth
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About Benetton
History and background of Benetton. Luciano, Giuliana, Gilberto and Carlo Benetton, launched the activities of the Benetton Group in 1965. The company is today present in about 120 countries around the world. Its core business is clothing with the fashion-orientated United Colors of Benetton and Sisley brands, The Hip Site, the brand for teenagers and the sportswear brands Read more about Benetton
More Benetton fragrancesfor Women: Colors , B United Jeans , Cold , Hot Perfume , Inferno Paradiso Pink , more
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This transaction went extremely well! So prompt, merchandise in top condition, will do business again anytime.
C. Heintz (Mt. Pleasant, MI)
Reviewed by 1 customer
- Alluring
- Clean & Fresh
- Draws Compliments
- Great Smell
- Great Value
- Subtle
Best Uses
- Daily Use
- Evening Use
- Seasonal
- Special Occasions
- Work
Comments about Funtastic Boy Cologne:
Can be used frequently or to surprise.. A nice sweet and intense mixture. It suggests liveliness and wish of new projects.
- Gift:
- No
- Fragrance Type:
- Citrus/Fruity, Fresh/Aquatic


text:
Several nutrition resources that have been translated into Spanish are available at the Penn State Dairy Cattle Nutrition web site.
The list of resource materials includes publications, spreadsheets and videos. Here is a list of some of the topics that are available in Spanish:
- Diet formulation and evaluation.
- Silage fermentation.
- Rumen function.
- Rumen development.
- Body condition scoring.
- Forage particle size.
Click here to access the materials.
Source: Penn State Dairy Cattle Nutrition Web site


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Milwaukee -- The Bon-Ton Stores announced that its "Your Rewards" loyalty program has been revamped and will be reintroduced beginning Feb. 15.
The new program will allow customers to begin earning rewards as soon as he or she $200 on their "Your Rewards" credit card at any of The Bon-Ton Stores seven nameplates, including Bon-Ton, Boston Store, Bergner's, Carson's, Elder-Beerman, Herberger's and Younkers or online.
The new program rewards customers in a much more tangible, flexible way, giving them a $20 Rewards Card for every $200 spent. Each reward can be applied to a purchase of $50 or more, with certain exclusions, or they can be accumulated and stacked for greater savings as they are earned.
Customers will be able to use multiple Rewards Cards with their purchases, thereby "stacking" their redemption which will start at $20 off $50 and increase as rewards are earned: $40 off $100, $60 off $150, $80 off $200 and up. For cosmetics or fragrance purchases, customers will receive $10 off a $50 purchase and they can stack the rewards to save even more.


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I just stayed for two weeks at this hotel while taking a photography class. The view of Venice every morning (from my balcony!) was wonderful, and the location right off the vaporetto was perfect. I didn't have to lug my bags very far, and found it quieter and more fun to be a step away. I know the Grand Canal sounds romantic, but I know I wouldn't have slept as well with the noise. That said, there was construction right outside the hotel, but it was quiet at night and fun to watch the Italian crew work during the day! Another guest had trouble opening and closing her shutters, so ask for help – they lock open and closed!
There is a restaurant right next door that is delicious (try the seafood zuppa).
Breakfast at the hotel is well stocked – Stella is very friendly and will make fresh cappuccino if you ask! Sabrina and Eugenio are a big help at the front desk during the day – a wealth of information, and I always felt safe with Francesco and Nicola at night.
The Wifi was very cheap – 10 euro for 24 hours lasted me two weeks as long as I logged out! Roomy bathroom – standard size room. I want to go back!!


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Business Centre
The latest business news, reviews, features and whitepapers
The FitBit Zip's tiny design, long-lasting battery and wireless synchronising capabilities make it a great "clip and forget" device that should keep you motivated. However, the non-backlit screen and the lack of an altimeter to count stairs climbed are downsides.
Earlier this year we reviewed the Fitbit Ultra, a wireless activity tracker or digital pedometer that counts your daily steps and logs the data in an easily presentable manner. Fitbit is now back with a smaller device that essentially does the same thing, with a few exceptions. The tiny Fitbit Zip remains a great motivational tool for a competitive price, though the lack of stair counting is a downside.
If you thought the Fitbit Ultra was small, you're in for a bit of a shock. The FitBit Zip is absolutely tiny. It's not much larger than a 20 cent piece and looks rather like a miniature Tamagotchi from the 90s (surely you remember those things?). The Zip itself is a smooth, gloss plastic shell, but it comes with a rubber holder with a clip on the back. Simply place the Zip in the rubber shell and clip it to your clothing. Our review unit was a black model, but the Zip is also available in white, pink, lime and royal blue colours.
The Fitbit Zip's tiny size means it's very easy to conceal under your clothing. It's so small and light that once we clipped it on every morning we forgot it was even there. The disadvantage to this is that its easily losable. While the belt clip itself seemed sturdy and never fell off our clothing, the tiny size of the unit means its very easy to misplace or lose when you do take it off. We lost two Fitbit Ultra units in the past, so had to be even more careful with the Zip.
The Fitbit Zip may be a cheaper unit than the Ultra but it does have a few significant design advantages. Firstly, it runs on a lithium watch battery so it doesn't need to be recharged. Fitbit says the battery should last between four and six months before needing replacing, and replacement watches are cheap and easily available. After more than three weeks of use everyday, the battery indicator on our review unit still showed full.
Secondly, the Zip has built-in Bluetooth connectivity so it can wirelessly sync to your computer with the included Bluetooth dongle or to an an iPhone 4S or iPhone 5 through the Fitbit app. Fitbit says the ability to sync with Android smartphones through the Android app is "coming soon", though the company has not specified when this will be available. We tested the Fitbit Zip with an iPhone 5 for a number of weeks and the ability to never have to plug the Fitbit into a computer to charge or sync is a fantastic feature.
The biggest disadvantage of the Fitbit Zip's design is its monochrome screen. Unlike the Fitbit Ultra, the screen doesn't have a backlight, so its impossible to see in the dark. We also found the screen hard to quickly glance at when we were walking.
The Fitbit Zip also lacks a few other features. It can't monitor your sleep, nor does it count stairs climbed. We didn't really miss the sleep monitor feature as we found it wasn't overly reliable on the Ultra model, but the lack of step counting is a downside.
The FitBit Zip is very simple to operate. There's no buttons on the unit so you simply tap the resistive display to cycle through the modes. Tapping the screen will display how many steps you've taken, how many kilometers you've walked, how many calories you've burned and the current time. As it's a resistive display, you need to tap rather hard on the screen and we often found that our taps weren't always responsive.
The Zip also shows a "recent activity level" in the form of a digital smiley face. If the face isn't smiling, you've been inactive recently. We found this rather useless and often couldn't tell the difference between the faces, though you can turn it off in the settings menu if you wish.
Like the Fitbit Ultra, the Zip really comes into its own when its synchronised with the FitBit.com Web site. Wireless syncronising to our computer worked relatively well during our testing and the device can be used with either a PC or a Mac.
If you have an iPhone 4S or iPhone 5, you can also set the Zip to sync periodically in the background using the Fitbit app. However, we found this a hit and miss affair. Sometimes our Zip would sync in the background and other times we needed to open the app and hit sync for the results to be logged.
Once you've registered for a free account the FitBit.com service tracks your data, calculates your daily results and displays them on multiple graphs and tables. You'll need to enter a fair bit of manual information when you first set up the FitBit: log your age, sex, height and weight and you're ready to go. Armed with your daily FitBit data, the service allows you to set personal goals, for example how many steps you want to strive for each day, or how many calories you want to burn. You earn badges for achieving these goals and can set them using the iOS and Android apps, too.
The FitBit service calculates and displays your daily activity breakdown, showing how long you've been sedentary, lightly active, fairly active or very active. Checking your results and setting new goals quickly becomes an addiction, helped along by a simple and straightforward user interface.
In addition to its step and calorie counting features, the FitBit Zip once again allows you to log your food intake and any physical activities you do, such as running or playing sport. Both the food log and the activity log are good ideas in theory but require a great deal of manual input to get the most out of. Despite a recent Australian launch, most of the foods in the FitBit database are American brands. You can add your own food entries but it's not really worth the time or effort.
The Fitbit Zip is available through Harvey Norman and other selected retail stores across Australia for $69.95.
• First look: Fitbit Zip wireless activity tracker
• Fitbit Ultra wireless activity tracker review
• Garmin Forerunner 610 GPS watch review
• Apple iPod nano (6th Gen) review
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Brother QL-820NWB Professional Label Printer
The print quality also does not disappoint, it's clear, bold, doesn't smudge and the text is perfectly sized.
Sharp PN-40TC1 Huddle Board
The Huddle Board's built in program; Sharp Touch Viewing software allows us to easily manipulate and edit our documents (jpegs and PDFs) all at the same time on the dashboard.
Sharp PN-40TC1 Huddle Board
The biggest perks for me would be that it comes with easy to use and comprehensive programs that make the collaboration process a whole lot more intuitive and organic
Brother PocketJet PJ-773 A4 Portable Thermal Printer
I rate the printer as a 5 out of 5 stars as it has been able to fit seamlessly into my busy and mobile lifestyle.
Brother PocketJet PJ-773 A4 Portable Thermal Printer
It's perfect for mobile workers. Just take it out — it's small enough to sit anywhere — turn it on, load a sheet of paper, and start printing.
HP OfficeJet 250 Mobile Printer
The HP OfficeJet 250 Mobile Printer is a great device that fits perfectly into my fast paced and mobile lifestyle. My first impression of the printer itself was how incredibly compact and sleek the device was.


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Local officials should ponder the implications of such questions before embracing a proposal that offers qualifying bar and restaurant owners a way around the state's population-driven quotas on the issuance of liquor permits in exchange for what might be perceived by even the least cynical among us as a $2,500 annual kickback.
Even if the legislation creating "Downtown Dining District" that was endorsed by the Downtown Improvement District this week and is headed to City Council for approval makes sense – and there is much to like about it – the unavoidable truth is that it represents just the latest example of how government all too often creates rules from which it later exempts individuals and groups for reasons that can be perceived as base even if they are not.
Was it just a coincidence that so many Democrat-friendly unions received Obamacare waivers?
I know, like, respect and trust many of the people promoting the proposal in Fort Wayne, which would create a district similar to those in 25 other Hoosier cities that have provided the special three-way permits to 137 businesses that meet certain qualifications. But when I hear those same people talk about how the permit-approval process could be somewhat arbitrary, or could favor the "right" kind of businesses over the "wrong" ones, I cringe.
And you should, too – if you care about transparency, integrity, fairness and the quaint but still legitimate notion that where business is concerned it should be the free market – not government – that determines who prospers and who fails.
As I reported Wednesday, advocates of the proposal believe the addition of bars and restaurants would complement other efforts to develop the riverfronts and attract more investment and people downtown. But because of the state quotes, no three-way licenses are currently available in Fort Wayne. Because of those limits, such licenses have been worth well over $100,000, although the price has fallen recently because of the soft economy and other factors.
But why is there even a quota at all? All the practice does is drive up the cost of doing business and limit competition – competition local officials are now trying to foster through the use of what can only be called waivers.
And who will get those waivers? There's the rub.
Some of the guidelines for the non-transferable permits are objective enough: be located within 1,500 feet of a river (except for historic structures); be located within a designated redevelopment area funded in part with federal, state or local dollars; meet all local requirements, existing state permit laws; derive at least half your sales from non-alcoholic items; be open at least 300 days per year, at least five nights per week. The $2,500 annual payment would go into a fund used to promote downtown.
But applicants must also be approved by the mayor and recommended by a still-unformed review board, which according to the proposal would have the "flexibility to take into account other factors, including total investment, financial strength and previous experience of the owner." Some have suggested locally owned businesses might be favored over chains.
Even if the process if totally impartial and above-board, its lack of consistent guidelines cannot help but encourage the perception of unfairness – especially since at least one member of the review committee must be a City Council member, whose campaign-finance reports will demand scrutiny to determine whether there is any connection between the approval of licenses and political contributions.
Ideally, all bars and restaurants would be on equal regulatory footing. It's more than a little unfair for one business to play by existing rules while new competitors get a potentially lucrative break. But if the city does go down this path – and I like a good drink as much as anyone – the process should at least be clear, consistent and predictable.
You meet the guidelines, you get your license and take your chances. No groveling, no guesswork.
And no funny business.


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Hello there, fellow members of the Pacers Digest #2 yahoo league.
This thread is for discussion leading up to the draft about the best draft date, and time, for the majority of owners.
After the draft, we can also start threads in here to talk about trades, injuries, or anything relating to the league.
It's much easier to communicate in here, instead of the small posting area at the bottom of the league page on Yahoo.
I PM'd Hicks, and gave him the list of members in our league, and asked if he would please unlock the yahoo fantasy league forum for anyone who can't access it already.
So if you've made it here, and have read this thread, please post below so we know what teams are ready to go.
I currently have the draft set for this Saturday the 9th, at 3:30 pm, Indiana time, but I can easily re-schedule it, if we need a better date where everyone can make it.
Don't forget to set your pre-draft rankings for your team, just in case something comes up at the last minute, and you can't make it. Yahoo's default rankings will always draft you a bunk team.
And also please remember to add a few individual defensive players to your rankings, they will be a part of the roster as well, D, DL, DB.
I am glad to have you all join, it should be a fun, and competitive league, and an exciting NFL season.


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Emily Bazelon
About the Author
Emily Bazelon is a senior editor at Slate, a contributing writer at The New York Times Magazine, and the Truman Capote Fellow at Yale Law School. Before joining Slate, she worked as a law clerk on the U.S. Court of Appeals for the First Circuit. She is a graduate of Yale College and Yale Law School, and lives in New Haven with her husband and two sons. This is her first book.


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ByChase Gummer
BERLIN—Zalando SE—the Berlin-based online clothing retailer—said this week it was testing out a new image recognition feature within its mobile app that allows users to take pictures of people on the go and get recommendations for similar clothing.
The company focuses on clothes and shoes, and is Europe's largest online retailer. It has grown rapidly since it was founded six years ago, is widely expected to launch an initial public offering later this year. The company said it was testing the image recognition technology in the German market. "The algorithm looks for color and pattern and bases suggestions on that," said Carolin Kühnel of Zalando's corporate communications.
The feature takes its cues from music identification apps like Shazam, and fashion tech app Asap54—which also pairs photos of clothing to stores' inventories. Amazon.com added a new image-recognition capability to its shopping app earlier this year.
In our tests, Zalando's image recognition app works moderately well. Pictures taken of people's clothes came close to the mark—the app suggested shirts and jackets that resembled the originals—but finding the right pair of jeans was more difficult. This is probably due to the fact that a trousers' cut is more important an indicator than color, causing the app to throw up a lot of random suggestions.
Still, the app opens another channel for Zalando users to find the clothing they are looking for, even though it's too early to tell how many shoppers will actually use the new function.
"We want to see how our customers use the new feature: will it be for an impulse buy or just for inspiration?" said Ms. Kühnel.
The company wouldn't say how many people use its mobile app. Executives did say that Zalando's website garners 100 million unique hits a month, and that a new website will be rolled out in September.
With more online commerce shifting to mobile, Zalando executives were also at pains to emphasize that over 40% of traffic in the second quarter came through mobile devices, but wouldn't say how many people actually purchase an item on a mobile device. A source familiar with the matter said Zalando's conversion rate on mobile wasn't very high, barely 5% of all transactions. Zalando would not comment on that figure.
Some evidence suggests that in Germany—one of Zalando's core markets—consumers are still adverse to using smart phones for purchases, fearing security breaches and finding the display too small, according to a study conducted by guenstiger.de, a German online price guide company. The same study, however, claims that 60% of Germans have bought at least one article on a tablet or PC.


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Don't miss out on a lower price on this hotel
Get an overview of this hotelDetroit Hotel in six historical buildings
Popular property highlights
Near historical museum
Located in the East Ferry Street Historic District of Midtown Detroit.
This Hotel is in Detroit, within one-quarter mile of the Detroit Historical Museum and the Detroit Institute of Arts. The Detroit Science Center is less than one-half mile away.
Buffet breakfast
The six buildings of Inn On Ferry Street are all more than a century old. This Detroit Hotel also offers complimentary buffet breakfast and a complimentary area shuttle within a 5 mile radius.
Wireless Internet
Each guest is welcomed with a complimentary cookie and water.
Guestrooms at Inn On Ferry Street offer coffee/tea makers, cable TV, and hair dryers as we as bottled water, and wireless Internet access.
Guest Highlights
- Friendly, helpful staff
- Spotless guestrooms
- Good location
- Breakfast
- Comfy beds and overall room comfort
The Inn On Ferry Street
Hotel Amenities
Hotel Amenities
Inn On Ferry Street occupies six Victorian homes and carriage houses, each more than a century old and with its period details intact. This Detroit property offers complimentary buffet breakfast; a complimentary shuttle takes guests within five miles. A fitness center is available nearby. This smoke-free Hotel offers coffee, tea, and fruit in the lobby. Complimentary PressReader access features thousands of newspapers and magazines from around the world. Wireless Internet access is complimentary throughout the property.
Laundry facilities are located on site, and dry cleaning is available. The front desk is open 24 hours a day and has a safe-deposit box. The Hotel provides secure free parking.
- Number of buildings/towers - 6
- 24-hour front desk
- Free breakfast
- Conference space
- Dry cleaning/laundry service
- Safe-deposit box at front desk
- Total number of rooms - 40
- Number of floors - 3
- Laundry facilities
- Concierge services
- Fireplace in lobby
- Free train station drop-off
- Gift shops or newsstand
- Computer station
- Tours/ticket assistance
- Limo or Town Car service available
- One meeting room
- Garden
- Porter/bellhop
- Luggage storage
- Year Built 1886
- 24-hour business center
- Free train station pickup
- Free self parking
- Smoke-free property
- Coffee/tea in common areas
- Free WiFi
- Free area shuttle
Available in all rooms: Free WiFi
Available in some public areas: Free WiFi
Free self parking
Room Amenities
- Cribs/infant beds (surcharge)
- Room service (limited hours)
- Premium TV channels
- Free bottled water
- Coffee/tea maker
- Daily housekeeping
- Hair dryer
- Iron/ironing board
- In-room climate control (air conditioning)
- Air conditioning
- Free toiletries
- Phone
- Desk
- Premium bedding
- Refrigerator (on request)
- Designer toiletries
- Private bathroom
- Bathtub or shower
- Television
- Portable fan
- iPod docking station
- Cable TV service
- Individually furnished
- Individually decorated
- Rollaway/extra beds (surcharge)
- In-room climate control (heating)
- Free WiFi
Where to Eat
Buffet breakfast is complimentary at Inn On Ferry Street.
Room service is available during limited hours.
Snack bar and wet bar located in reception area.
Nearby Things to Do
The recreational activities listed below are available either on site or nearby; fees may apply.
- Golfing nearby
- Free bicycles on site
If you have requests for specific accessibility needs, please note them at check-out when you book your room.
- Accessible bathroom
- Roll-in shower
Hotel Policies
Minimum check-in age is 21
Check-in time ends at 3 AM
Check-in time starts at 3 PM
Check-out time is noon
Payment types
Children and extra beds
- Children are welcome.
- Rollaway/extra beds are available for USD 25.00 per day.
- Cribs (infant beds) are available for USD 15.00 per day.
- Pets not allowed
You need to know
Extra-person charges may apply and vary depending on property policy.
- Deposit: USD 200.00 per stay
Optional extras
- Refrigerator fee: USD 25.00 per night
- Crib (infant bed) fee: USD 15.00 per day
- Rollaway bed fee: USD 25.00 per day
Hotel Name
- Ferry Inn
- Ferry Street Detroit
- Ferry Street Inn
- Inn Ferry Street
- Inn Ferry Street Detroit
- Inn On Ferry Street Hotel Detroit
- Ferry Street
- Inn On Ferry Street
Awards & Affiliations
- The property is a member of Historic Hotels of America.


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We have received images of the fascinating project, SPACEPLATES Greenhouse Bristol, a class room and growing space for the horticulture students and their teachers at the South Bristol Skills Academy in Bristol, UK. The project is a collaboration of Danish artists' group N55 with Copenhagen architect Anne Romme. — bustler.net
Current tag:
SUBMIT NEWS: submit in 60 seconds!


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To Compare the Efficacy of Endoscopic Ultrasound Assisted Endoscopic Glue Injection and Conventional Endoscopic Injection Therapy for Prevention of Gastric Variceal Rebleed
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- How to Read a Study Record
Consecutive patients who meet the eligibility criteria will be enrolled into the study. All patients with gastric varices with no history of gastric variceal bleed (Group C) will undergo Endoscopic ultrasound and Upper Gastrointestinal Endoscopy at baseline, at the end of first year and at the end of study.
The patients who presented to Institute of Liver and Biliary Sciences with gastric variceal bleed or develop Gastric Variceal bleed during hospital stay will be randomized into Group -A (conventional Upper Gastrointestinal Endoscopy + Glue) and Group-B (Endoscopic Ultrasound followed by Upper Gastrointestinal Endoscopy+Glue) therapy for gastric varices. Total 90 patients will be enrolled and randomized into group A and Group B after resuscitation and urgent Upper Gastrointestinal Endoscopy with standard therapy for bleeding gastric varices to achieve hemostasis.
|Bleeding Gastric Varices
|Procedure: Endoscopic Ultrasound assisted endoscopic glue injection Procedure: Standard Endotherapy
|Phase 3
|Study Type:
|Study Design:
|Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Participant)
Primary Purpose: Treatment
|Official Title:
|Phase III Study of the Efficacy of Endoscopic Ultrasound (EUS) Assisted Endoscopic Glue Injection and Conventional Endoscopic Injection Therapy for Prevention of Gastric Variceal Rebleed
- Proportions of patients with gastric varices develops rebleed after complete gastric varices obturation in 2 years [ Time Frame: 2 years ]
- Proportion of patients who will achieve complete Gastric variceal obliteration in both groups [ Time Frame: 2 years ]
- Proportions of patients who will show adverse effects of gastric variceal obturation by N Butyl cyanoacrylate. [ Time Frame: 2 years ]
|Study Start Date:
|June 2012
|Estimated Study Completion Date:
|June 2014
|Estimated Primary Completion Date:
|June 2014 (Final data collection date for primary outcome measure)
|Assigned Interventions
|Active Comparator: standard endotherapy
Procedure: Standard Endotherapy
Patients will be stabilized by giving i/v fluids, blood and blood products. Injection terlipressin will be given to all patients in a bolus dose of 2mg within 30 minutes of admission to the hospital. This would be followed by 1mg i/v 6hrly and will be continued for 5 days. If terlipressin cannot given then inj.somatostatin 500mcg IV bolus followed by 250mcg/hr continuous infusion for 5days.
|Experimental: Endoscopic Ultrasound assisted endoscopic glue injection
Procedure: Endoscopic Ultrasound assisted endoscopic glue injection
N Butyl cyanoacrylate will be used for achieving initial hemostasis during active gastric variceal bleed and during follow up gastric variceal obturation. Endoscopic injection will be performed intravariceally using a therapeutic endoscope and a steel hubbed catheter, with N-butyl-2-cyanoacrylate. The cyanoacrylate will be injected without dilution with lipiodol. The tip of the endoscope will be coated with lipiodol to prevent sticking of glue to the endoscope. The injection catheter is primed with saline solution followed by injection of glue in 1ml aliquot to fill the dead space followed by injection of sterile water to flush the glue into the varix. The needle is withdrawn immediately after the glue injection to prevent tissue adherence.
|Ages Eligible for Study:
|18 Years to 70 Years (Adult, Senior)
|Sexes Eligible for Study:
|Accepts Healthy Volunteers:
Inclusion Criteria:
- A clinical, radiological or histologic diagnosis of cirrhosis
- Upper Gastrointestinal endoscopy showing gastric varices
- Informed consent to participate in the study
Exclusion Criteria:
- Previous endotherapy (Endoscopic Variceal Ligation/Esophageal Variceal Sclerotherapy/Endoscopic Variceal Obliteration) for gastric variceal haemorrhage
- Diagnosed case of HepatoPulmonary Syndrome.
- Non -cirrhotic portal hypertension/Extra hepatic Portal Venous Obstruction
- transhepatic intrajugular portosystemic shunt, (balloon-occluded retrograde transvenous obliteration), balloon-occluded endoscopic injection sclerotherapy, shunt operation.
- Hepatic encephalopathy grade III/IV,
- Cardio respiratory failure
- Pregnancy
Please refer to this study by its ClinicalTrials.gov identifier: NCT01631890
|Institute of Liver and Biliary Sciences
|New Delhi, Delhi, India, 110070
|Principal Investigator:
|Ashok Kr Choudhury
|Institute of Liver and Biliary Sciences
|Responsible Party:
|Institute of Liver and Biliary Sciences, India
|ClinicalTrials.gov Identifier:
|NCT01631890 History of Changes
|Other Study ID Numbers:
|Study First Received:
|June 14, 2012
|Last Updated:
|November 7, 2015
Additional relevant MeSH terms:
Esophageal and Gastric Varices
Esophageal Diseases
Gastrointestinal Diseases
Digestive System Diseases
Hypertension, Portal
Liver Diseases
ClinicalTrials.gov processed this record on September 21, 2017


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You are here: Kidspot Activity Corner Maths games for kids Fraction card game
Fraction card game
This fraction card game makes learning about fractions fun - so fun, they're going to forget they're actually practising their fractions. There is a full set of fraction cards for you to download and print out. Get started now!
Number of players:
2 +
What you need:
- computer with internet access
- paper for printing out fraction cards
Create your fraction game by printing out the FREE printable on this site.
Once you've printed them out, stick them to cardboard to make them a bit sturdier. Get the kids to trace around the fractions with a blue and red merker if you don't have a colour printer. There should be three types of cards: blue cards, red cards and wild cards.
- Variations of the game include Snap! or Memory but follow the rules and the kids will get a lot more out of the game.
Visit the website now to get started.
Learning benefits of play, craft and activities:
- Benefits of crafts for kids
- Craft ideas to make for babies
- Why reading is important
- Your child's development milestones
- Why play makes kids smarter
- The importance of outdoor play
- Types of play
- How craft helps unplug kids from screentime
Find some fun with printables:
- Chore and reward charts
- Colouring pages
- Easy mazes
- Medium level mazes
- Hard level mazes
- Medium dot-to-dots
- Hard dot-to-dots
- Colour by numbers


text: +-------------------------------------------------------------------------+ | TPWD News Release 20091105d | +-------------------------------------------------------------------------+ | This page contains only plain text, no HTML formatting codes. | | It is not designed for display in a browser but for copying | | and editing in whatever software you use to lay out pages. | | To copy the text into an editing program: | | --Display this page in your browser. | | --Select all. | | --Copy. | | --Paste in a document in your editing program. | | If you have any suggestions for improving these pages, send | | an e-mail to email@example.com and mention Plain Text Pages. | +-------------------------------------------------------------------------+ [ Note: This item is more than seven years old. Please take the publication date into consideration for any date references. ] [ Media Contact: TPWD News, email@example.com, 512-389-8030 ] [ Additional Contacts: Rob McCorkle (830) 866-3533, or email@example.com; Ted Hollingsworth (512) 389-4520 or email@example.com ] Nov. 5, 2009 Land Deal to Double Size of Village Creek State Park AUSTIN, Texas -- Village Creek State Park in southeast Texas will more than double in size as a result of action taken Thursday by the Texas Parks and Wildlife Commission directing the acquisition of roughly 1,420 acres of undeveloped timber land owned by The Conservation Fund. At its regular meeting in Austin, the commission approved the bargain sale purchase of the Hardin County tract that abuts the southern boundary of the 1,090-acre state park near Lumberton. The long sought-after acreage will protect critical habitat from urban encroachment and enhance Village Creek State Park's connection to the Big Thicket National Preserve's Village Creek and Neches River Corridor units. "This is an exciting acquisition that will more than double the size of the park and provide for a better visitor experience," said Texas State Parks Director Walt Dabney. "It's a perfect example of how a public-private partnership can work to benefit the environment and all Texans." Village Creek State Park, which opened in 1994, is blessed with a diverse habitat that includes longleaf pine uplands, wetlands and cypress swamps, as well as two miles of valuable creek frontage. Sixty-nine-mile long Village Creek is recognized as one of the last free-flowing streams in East Texas and is home to rare fish and mussels. TPWD has been working for some time with the Fund to acquire the additional acreage to protect the park from encroaching development on its fringes resulting from the City of Lumberton's accelerating growth. The acquisition brings several major benefits. It will expand outdoor recreational opportunities for park visitors, protect important habitat for plants and animals, and for the first time, provide state park personnel with vehicle access to the eastern third of the existing state park. TPWD has an agreement with the National Park Service that will allow cooperation to explore additional public access to Village Creek through Big Thicket Preserve property adjacent to the 1,420-acre tract. Current logging roads would be used for park trails. The Conservation Fund, through a creative combination of public and private grant funding, was able to offer the additional acreage to TPWD at about one-quarter of its market value. Andy Jones, Texas director of The Conservation Fund, praised the cooperative effort. "I started my career at Texas Parks and Wildlife and working with the department again is like a homecoming for me," Jones said. "It is an honor to work with their dedicated and very professional staff to protect this key property for future generations." The Conservation Fund is the nation's foremost environmental nonprofit dedicated to advancing America's land and water legacy for current and future generations. Seeking innovative conservation solutions for the 21st century, the Fund works to integrate economic and environmental goals. Since its founding in 1985, the Fund has helped its partners safeguard wildlife habitat, working landscapes, community "greenspace" and historic sites totaling more than 6 million acres. Village Creek State Park, located about 10 miles north of Beaumont, is back in full operation after suffering considerable damage from Hurricanes Rita and Ike. Unique in the state park system, Village Creek preserves a small slice of the 96,000-acre Big Thicket, known as the "biological crossroads of North America, due to its incredible ecological diversity. The park draws tens of thousands of visitors annually to camp, hike, fish, mountain bike, canoe and view wildlife that includes more than 200 species of birds. --- On the Net: http://tpwd.texas.gov/spdest/findadest/parks/village_creek/ http://www.conservationfund.org/ -30-


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Friends of the Osseo Library will be hosting its annual Book Sale during Osseo Lions Roar Days. The sale will be Friday, Sept. 7, from noon to 4 p.m. and Saturday, Sept. 8, from 9 a.m. to 4 p.m. in the community room of Osseo City Hall, 415 Central Ave.
If anyone has books to donate, bring them to the Osseo Library during its open house. Arrangements can also be made to pick up donations by calling Friends President Connie Ellingsworth at 763-424-2883.


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*On December 27th, EOXLive published a 2013 outlook for crude oil and natural gas. If you have not received it or would like a copy, please email firstname.lastname@example.com.
Energy Price Outlook
The oil market may remain in a mixed trend in the near-term as it has in the last three sessions, with underlying factors somewhat balanced. Recent support has been given by improved signs of economic growth, COT data, the grounding of Shell's oil rig in Alaska, and the ramp-up of the expanded Seaway pipeline this week. Environmental groups have already called on the president to suspend drilling permits in the Arctic. Opposing pressure will be provided by the possibility of a rebound in crude oil stocks in Wednesday's DOE report, potentially weaker demand in light of higher prices, and from technical resistance near $94.00. The pipeline expansion should help WTI against Brent crude, and we entered a spread recommendation in June futures at -$14.25 on Friday morning, with a target at -$8.00.
Yesterday's trade settled 10 cents higher in WTI and 9 cents higher in Brent. The market seemed to gain support once again from the prospect of improved economic conditions. The Chinese PMI data a week ago helped to kick-start the rally, while the payroll report and fiscal cliff solution gave another boost last week. The delay of Basel 3 capital increases for banks helped the European markets trade higher yesterday. These factors also led to a new five-year high in the S&P 500 index on Friday, which is also a precursor to future growth. Large funds have picked up on these developments, and added 18,992 contracts to the managed money net long through last week. The non-commercial category saw an inflow of 3,371 contracts.
The Brent-WTI differential may continue to narrow in the near-term, as the Seaway pipeline is scheduled to ramp-up to full rates this week. The pipeline runs between Cushing Oklahoma and Freeport Texas, and will begin transporting 400 kb/d of WTI crude to the Gulf Coast rather than the 150 kb/d that was the case previously.
Global Economic & Dollar News
» Basel III Regulations were relaxed in order to give banks four more years and additional flexibility to build up cash reserves.
» The White House may use the framework of spending cuts that were being discussed in Dec as a starting point for new talks in front of the debt ceiling. Pres Obama, however, still wants to raise $600B in new revenue through cutting deductions and closing loopholes.
» Senate Minority Leader McConnell reiterated over the weekend that the tax issue is over and that the focus needs to turn to spending.
Upcoming Events
Tue - API Inventories (4:30pm EST)
Wed - EIA Weekly Oil Inventories (10:30am EST)
Thu - ECB & BOE Meetings
Thu - Natural Gas Inventories (10:30am EST)
Jan 16th - Iran-IAEA Meeting
Jan 29-30 - FOMC Meeting
Mar 1st - Sequester Begins
May 31st - OPEC Meeting
EIA Inventory Preview
Crude oil stocks may reverse the downward trend that usually takes place at year-end and begin building again. Our expectation is for a build of 2.0 MB this week. The five-year average shows an increase of around 41.6 MB between the last week of the year and the peak in inventories in early-May, as refiners add to stocks in anticipation of the summer demand season. In the current week, the five-year gains 0.6 MB. Support for inventories may be offered by a rebound in imports, which typically recover strongly in the first couple weeks of the year. Demand may add as well, as consumer demand may have been rationed due to late-Dec price gains as well as worries over the fiscal cliff. Some spillover effects of the cliff may have included weakness in equity prices, which may thus have offered a reverse wealth effect. On the flipside, pressure on inventories may come from utilization levels that ended 2012 more than 5.0% above the five-year average.
Gasoline inventories typically build sharply into early-Feb before supplies begin being shipped for increases in demand tied to late-spring and the summer driving season. We would anticipate a build of 3.0 MB in gasoline and 3.0 MB in distillates. The level of distillate stocks recovered late in 2012 due both to higher refinery production as well as weakness in demand.
Natural gas inventories may fall 170 bcf this week, as heating degree days increased to around 238 from 212-220 previously. Temperatures were generally below-normal across the majority of the country from west to east, with the exception of the northern Great Plains and parts of the desert Southwest. The 238 degree day reading is higher than anything seen last season, where the peak was made at 218-220. Inventories fell 192 bcf that week in what was the largest draw of the season. Given increased production levels being seen this year, however, we wouldn't anticipate any draw that large.
*The API convergence figures are the amounts that EIA data need to change in order to match the previous day's API figures
Grains Commentary
Published Monday morning, 1/7/12
The markets are trying to recover from the bad hang over of the first week of 2013 as grain markets are testing areas that have not been seen since before the start of the worst drought in 100 years.
The genetics of these seeds continue to amaze nearly everyone as Informa now pegs the bean yield over 40 bushels an acre, this is with basically 1 decent rain event in late August, it's going to be nearly impossible to get anyone to believe that a drought can do that much damage to a crop ever again. We say this with some sarcasm as we have learned that it's not necessarily the amount of rain but rather the timing of it. The reality is that once again the world continues to consume nearly every grain that is produced and with the high prices the global expansion of grains is at a pace that has never been seen before, but does this pace continue if prices drop? The likelihood is not. As of today Ukraine is offering corn cheaper than Argentina and Argentina is still cheaper than the US, so the bottom line is that the US is not priced to do any business and with SA harvest only weeks away the window for doing export business is quickly coming to a close. The beans are facing the same dilemma as SA harvest is already under way and they are only weeks away from getting the exports started in a robust way.
The USDA will issue the final production figures on Friday and over the past 5 of 6 years the market has experienced a limit move on this day. The reality is that even with tighter stocks (if they even are) the market may quickly rally but be faced with tremendous selling from SA and other growing regions.
The weather in SA remains very good for crop development and appears that record crops will be produced in nearly every corner of SA. The only concern now (and its short lived) is that some of the early harvesting areas are experiencing excessive rain and is postponing some harvest, it needs to be noted that this is not hurting the crops only delaying some of the harvest.
The OI changes in futures shows the index activity as wheat increased by 5016, meal increased by 3523, and beans fell by 171, oil was down 2437 and corn fell by 182.
The option markets quickly caught a bid to things last week as both movement picked up and the return of capital also came back into play. The options will most likely continue to have bids to them throughout the week as the January report is one that has proven to be a vicious market mover. The future spreads are still heavily inverted in corn which still seems to point towards owning the gamma over the Vega. The meal premium is 3-4% over the beans which at this point seems like it should be sold vs. beans. The CH-WH has fallen to the lowest levels in months while the deferred are still much higher, look to own WH calls vs. CH calls and in the deferred to own CZ calls vs. selling WZ calls.


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HAART Adherence Among HIV-infected Persons and the Factors Affecting Treatment Adherence
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- How to Read a Study Record
|Acute HIV Infection Acquired Immunodeficiency Syndrome Medication Adherence
|Behavioral: Advanced Adherence Counseling (AdvAdh)
|Study Type:
|Study Design:
|Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
|Official Title:
|HAART Adherence Among HIV-infected Persons and the Factors Affecting Treatment Adherence
- Change in HAART adherence level (HIV RNA and CD4 count) [ Time Frame: Data analysed at study months 6 and 12 ]HAART adherence is monitored and change at month 6 and 12, as compared to baseline is recorded and compared between the AdvAdh intervention and the control group. For assessment of the effects regression analysis is used. Percentage of patients with HIV-1 RNA level <50 copies/mL in the two study groups is measured at baseline and months 6, 12; and changes from the original log10 HIV-1 RNA level and cluster of differentiation four (CD4) count are compared at months 6, 12. Factors related to achieving HIV-1 RNA level of <50 copies/mL and HAART adherence >95% are assessed.
- Study subjects retention in study [ Time Frame: Data analysed at end of study (month 12) ]
- Change in quality of life of study subjects [ Time Frame: Data analysed at study months 6 and 12 ]Quality of life of study subjects (SF-10) is measured at baseline and study month 6 and 12 in both study groups. Change from baseline is calculated.
|Study Start Date:
|July 2010
|Study Completion Date:
|December 2011
|Primary Completion Date:
|December 2011 (Final data collection date for primary outcome measure)
|Assigned Interventions
Experimental: Advanced Adherence Counseling (AdvAdh)
Please see the Intervention Description section
Behavioral: Advanced Adherence Counseling (AdvAdh)
AdvAdh consists of 3 individual sessions (study months 0, 3, 6) -- patient-centered, non-judgmental, Motivational Interviewing- and theory-based, semi-structured, brief, candid conversations with a trained clinical care nurse using Next Step Counseling (NSC) approach. The intervention targets: 1) accurate information about antiretroviral treatment (ART) (mechanisms of HIV and antiretrovirals) and the development of mental imagery around it; 2) promotion of perceived sense of ease and efficacy in working ART regimen into the context of one's daily life and present life circumstances that may challenge drug use persistence; 3) identification, refinement of skills promoting ease of adhering to one's ART regimen across the diverse and challenges contexts.
Other Name: Situated Optimal Adherence Estonia (sOAI Estonia)
No Intervention: Control
Standard of care (including counseling regarding antiretroviral treatment adherence) received by HIV/AIDS patients at the study clinic
Detailed Description:
Specific HIV treatment - HAART (Highly Active Antiretroviral Therapy) can suppress HIV replication and consequently preserve the functioning of immune system. HAART therapy is a lifelong treatment with several different concomitantly administered oral medications. According to studies, low adherence to treatment is directly related to patient's knowledge and beliefs about HAART.
Studies have shown the success of different interventions increasing adherence to HAART, but additional studies need to be carried out in order to determine the most effective components of the interventions and the methods most suitable considering the local context, that could be used in everyday work and with limited resources.
The first places to implement the activities directed at improving treatment adherence are medical institutions, i.e. the departments of infectious diseases where HIV-positive individuals receive HAART treatment.
The aims of the study are:
- to determine the rate of adherence to HAART and its associated factors;
- to conduct a small-scale intervention (randomised controlled) study implementing a brief adherence counseling targeting persons receiving HAART.
|Ages Eligible for Study:
|18 Years and older (Adult, Senior)
|Sexes Eligible for Study:
|Accepts Healthy Volunteers:
Inclusion Criteria:
- HIV infected;
- ≥18 years of age;
- speak and read either Estonian or Russian;
- receiving or starting a HAART regimen
Exclusion Criteria:
- triple class antiretroviral drug resistance, as determined from a prior resistance test performed in clinical practice, defined according to International Antiviral Society - USA (IAS-USA) interpretive guidelines for genotypic resistance mutations
Please refer to this study by its ClinicalTrials.gov identifier: NCT01369056
|Ida-Viru Central Hospital
|Kohtla-Järve, Ida-Viru County, Estonia, 31025
|Principal Investigator:
|Anjali Sharma, MD, MSc
|State University of of New York Downstate Medical Center
|Principal Investigator:
|Anneli Uusküla, MD, MSc, PhD
|University of Tartu Department of Public Health
Additional Information:
|Responsible Party:
|Anneli Uusküla, Principal Investigator (Professor of Epidemiology, Department of Public Health), University of Tartu
|ClinicalTrials.gov Identifier:
|NCT01369056 History of Changes
|Other Study ID Numbers:
|Study First Received:
|June 3, 2011
|Last Updated:
|May 24, 2016
|Individual Participant Data (IPD) Sharing Statement:
|Plan to Share IPD:
Keywords provided by Anneli Uusküla, University of Tartu:
antiretroviral therapy, highly active
treatment adherence
Additional relevant MeSH terms:
HIV Infections
Immunologic Deficiency Syndromes
Acquired Immunodeficiency Syndrome
Lentivirus Infections
Retroviridae Infections
RNA Virus Infections
Virus Diseases
Sexually Transmitted Diseases, Viral
Sexually Transmitted Diseases
Immune System Diseases
Slow Virus Diseases
ClinicalTrials.gov processed this record on September 21, 2017


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The Flyers could come out of the draft with bigger news to follow. On June 25, clubs are permitted to extend offer sheets to Group II restricted free agents. According to league sources, the Flyers are seriously considering offering Buffalo's Thomas Vanek an offer sheet.
The 23-year-old left winger would be an immediate upgrade in terms of mobility, skill and scoring. He scored 43 goals last season with the Sabres, playing on both scoring and checking lines.


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Fairfax 50+ Action Plan Released at Board of Supervisors Meeting
Fairfax County Office of Public Affairs
12000 Government Center Parkway, Suite 551
Fairfax, VA 22035-0065
Contact: Merni Fitzgerald, Director of Public Affairs
703-324-3187, TTY 711, Fax 703-324-2010
Media Pager: 703-324-NEWS (6397)
Oct. 15, 2007
Fairfax 50+ Action Plan Released at Board of Supervisors Meeting
Chairman Gerald E. Connolly and the Fairfax County Board of Supervisors released an action plan today in anticipation of the "silver tsunami," a demographic shift that is projected to result in a 32 percent increase in adults ages 50+ in Fairfax County by 2020.
"Anticipating the Future: Fairfax 50+ Action Plan 2007" is the first product of the board's focus on the opportunities and challenges of this demographic shift; a shift that will affect programs and services countywide. The board began this project in January 2006 with the formation of the Committee on Aging, the first new board committee in more than a decade. Issues tackled by the committee to date, with the aid of experts in each field, include the critical and interdependent issues of housing, community planning, care giving, health, mental health, transportation, technology and diversity.
"Our older adults are increasingly choosing to keep Fairfax County as their home. By acting now, we'll ensure that the county remains aging friendly," said Connolly.
The Fairfax 50+ Action Plan is not a report on the actions taken but the actions to be taken to ensure the needs and talents of those 50+ are included in the future of the community. It is organized into 11 focus areas and is a starting point for moving toward a more aging-friendly Fairfax County. The focus areas will become a score card for the community to use in the future:
Are we engaging older adults with a wealth of talents and skills as
employees, entrepreneurs, volunteers and community activists?
Are we supporting caregivers?
Are we using advances in technology that will allow older adults
greater independence?
Are we creating and revitalizing Fairfax County to enable independence
and are we including design elements of a livable community for all
Are we providing housing options that meet the needs of every age and
are easily adaptable?
Are we addressing the affordability of housing, programs and services
to a segment of the population that is likely to have limited
Are we ensuring independence through transportation planning that
includes a range of options for older adults?
Are we building on the diversity of our population to enhance the
cultural richness of our community and services?
Are we ensuring that our health care and mental health care systems
keep pace with the aging of our population?
Are we enhancing the personal safety and security of our older adults
through emergency preparedness and consumer education?
- Are we planning appropriately in the community for an increased demand for older adult services?
This action plan outlines the work that must be done to answer these questions. It marks a shift in how the county plans, so that when policy decisions are made the questions asked include: "What is the impact on older adults? What opportunities does this new policy provide?"
"Today's older adults have a history of giving back to our community. We must ensure that every opportunity is in place for the boomers to follow their lead," said Lee District Supervisor Dana Kauffman, chair of the board's Committee on Aging.
In releasing Fairfax 50+ Action Plan, the Board of Supervisors is setting the agenda for the future and focusing the communitywide discussion that will continue as Fairfax County prepares for this demographic shift. A survey of thousands of communities in September 2006 found that the majority of local governments had not begun planning for the inevitable demographic shift ("The Maturing of America – Getting Communities on Track for an Aging Population" by the International City/County Management Association, National Association of Counties, National League of Cities and Partners for Livable Communities). Fairfax County is unique because its planning has taken place hands-on at the highest level – the elected official level – and builds on the solid comprehensive demographic study "Anticipating the Future – A Discussion of Trends in Fairfax County (2006)" initiated by the Board of Supervisors in May 2004.
The work of the board's Committee on Aging and this action plan have begun to take hold within county government as departments begin to integrate aging-friendly policy into future plans. "Since so much of our work force is part of this demographic sea change, they have embraced the chance to make needed changes and set a high standard for other levels of government to follow," said Connolly.
More than 60 initiatives are planned, including flexible, meaningful volunteer opportunities, health promotion activities, development of respite options for caregivers, increased education about subprime lending targeted to older adults and staff training on identifying elder abuse.
The full plan is available online at www.fairfaxcounty.gov/olderadults.
For more information about the Fairfax 50+ Action Plan and/or to get a printed copy, contact the Department of Family Services, Area Agency on Aging at 703-324-5411, TTY 711 or e-mail firstname.lastname@example.com.
For more news and information, visit www.fairfaxcounty.gov/news.


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This game was classified by the community with the following category scores - Violence=0/3, Sex=0/3, Mature Content=0/3. Test your reflexes in this fast-paced, one-button classic. Race through procedurally generated levels, dodging obstacles in your path. Can you complete the twisted loop that is Mobius?
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Almost a year ago, we started a profoundly personal conversation about the sorry state of dying in America.
The discussion, inspired by my frail 88-year-old father's expensive hospital death, has taught me that too much drama and desperation consume our final days, lending them too little dignity.
Today, I want to build on our conversation and prescribe a cure -- a new way of considering end-of-life medicine -- in the final installment of our yearlong examination of the emotional and financial Cost of Dying.
It is not a drug or a device, a test or therapy. It is a different way of organizing our ending -- so that we live our last days better and pass more gently.
Powerful lessons have emerged from the stories of suffering and triumph we have shared -- not only through the reporting but from dozens and sometimes hundreds of emails and phone calls from readers. Together, we've met Bay Area people like Ray Brown, who showed how agonizing it can be when a loved one's end-of-life wishes are unknown. And doctors like Jessica Zitter, who insists it's the doctor's job to help families decide whether it's time to quit. We admired the resolve of Bill Newman, who wears his end-of-life wishes on a homemade "Do Not Resuscitate" badge, and marveled at caregivers like Susan Meyers who sacrificed her own well-being to allow her beloved husband, John, to die at home.
And we were privileged to share Gayla Caliva's own goodbye, as the retired hospice nurse from San Jose chose to enjoy stargazing and spicy foods with friends instead of exhausting and painful dialysis.
The real miracle? Places as different as a community in Wisconsin and Oakland's Highland Hospital are showing the way to a death that is kinder and less expensive. Medicare has become the single biggest contributor to the country's long-term budget deficit, according to the Congressional Budget Office. And a quarter or more of Medicare costs are incurred in the last year of life.
"Everyone says they don't want to die in a hospital, with tubes in every orifice," said U.S. Rep. Jackie Speier, D-San Mateo. She saw the two paths of medicine when her parents died. She lost her 92-year-old mother after an angioplasty meant to improve her life instead led to intensive care and nine months of decline. Her father, in contrast, died after five days in hospice, his pain controlled.
If we want to improve end-of-life care, "there are ways to do it -- but we have to commit to it," she said.
Some of the solutions can start at home tonight, at the dinner table. Others are more formidable, requiring doctors, hospitals and federal health policy to change.
Our conversation has taught us that, yes, there is a cure for the cost of dying in America. It will reduce suffering and expense, and here's how we begin:
Cure 1: Take charge of our deaths by putting wishes in writing
While 82 percent of Californians say it is important to have end-of-life wishes in writing, only 23 percent of us have done so, according to a poll by the California HealthCare Foundation.
And that changes with you.
Newman, an 87-year-old double bypass survivor from Capitola, taught us it's our responsibility to participate in decisions about our care and to delegate someone to represent us. Not only does he wear a DNR badge, he posted the same message on his refrigerator and shared it with his doctor and 10 children. Like him, we have a responsibility to speak up, before our voices weaken and fail.
You -- not doctors, not nurses -- are the expert on your wishes about end-of-life care. First, tell your loved ones. Secondly, appoint someone to act as your bedside advocate. Many new online resources can help you get started, such as The Conversation Project, advance care planning videos by the Coalition for Compassionate Care of California, and advance care directive forms at www.mercurynews.com/cost-of-dying.
If you or your loved one is seriously ill, frail or very elderly, ask your doctor for a POLST (Physician Orders for Life-Sustaining Treatment) form. The bright pink form turns your treatment wishes into a medical order.
Cure 2: Involve entire communities in commitment to planning
Doctors who don't know our wishes can't honor them. That's why one entire Wisconsin community set out to make sure its residents' end-of-life decisions were as much a part of their personal medical records as their blood pressure medications and peanut allergies.
The physician-led nonprofit Gundersen Lutheran Health System in La Crosse hired a facilitator whose sole job is to discuss advance planning with every patient -- even young, healthy people -- so that their wishes appear in electronic medical records easily transferred from facility to facility. This system, called "Respecting Choices," required an investment of time, money, training and organization. But the result? A stunning 96 percent of the community's adult residents who died during a seven-month period in 2010 had documented their wishes -- and end-of-life medical costs are low. "Respecting Choices'' has since been replicated in more than 60 organizations in the United States, as well as nationally in Australia and Singapore.
Oregon created a statewide electronic registry for POLST advance care directives in 2009. In 2011, the registry's second full year of operation, there were more than 200 instances when 911 medics racing to an emergency knew a person's medical wishes before they arrived.
Hospitals in California, like those in Wisconsin, could ensure that patient electronic records include an advance directive or POLST order, assuring rapid access to patients' end-of-life choices. Ultimately, a statewide registry, like Oregon's, could be created.
Cure 3: Encourage doctors to talk more frankly about choices
Doctors are adept at describing blood pressure, kidney function or cardiac output. But hospitals and medical schools need to do more to train doctors to answer questions about the effectiveness and necessity of treatment.
"It's scary for doctors to talk about," said Zitter of Oakland's Highland Hospital, who meets with families of ICU patients at least twice a day, often in tense circumstances. "It's much simpler to just keep treating the kidney problem, or the lung problem, without talking about it."
"But if people really understood the truth about their medical situation, they will make educated choices," she said. "They are less likely to get carried along this train ride of intensive care."
UC San Francisco and other schools are starting to train doctors how to break bad news and outline hard choices.
We can help, by asking critical questions: Is a cure still possible? What do you expect in the next few weeks or months? Is there treatment to prolong life? What kind of life will it be?
Cure 4: Pay doctors to help patients decide what's best for them
Doctors are paid to operate and prescribe drugs or radiation, but they aren't paid to talk to families.
Medicare and insurance companies need to reward doctors to guide families through essential medical decisions -- especially because these conversations can help us get the right care when it matters most, with big cost savings.
These are time-consuming dialogues. If another round of chemotherapy is attempted, what are the side effects? Will a feeding tube be temporary -- or permanent?
But the system discourages such engagement.
"Insurers, Medicare and Medi-Cal more readily pay for diagnosis and treatment than anything else that doctors do," said Dr. Ira Byock of Dartmouth-Hitchcock Medical Center in Lebanon, N.H.
Early legislation to reform the nation's health care system tried to pay doctors for these conversations. But remember "death panels"? That partisan label torpedoed the idea by conjuring up images of bureaucrats deciding which patients were worthy of care.
But the idea is back, as U.S. Rep. Earl Blumenauer, D-Ore., plans to reintroduce HR1589, the "Personalize Your Care Act" in the new session.
Cure 5: Avoid costly care that won't prolong or improve life
Medicare stimulates the creation of new tools to combat death -- even where effectiveness is questioned. That's because its reimbursement rules virtually guarantee that drug and device manufacturers have a market for any product aimed at people older than 65. And who profits? U.S. drug companies and device-makers who ring up hundreds of billions of dollars in domestic sales annually and make up a powerful lobby.
Since Medicare was established in 1965, it has precluded consideration of cost in coverage decisions. Changing the law could fix that.
For example, Medicare covers the $80,000 to $100,000 cost of the lung cancer drug bevacizumab, despite uncertain benefits in patients older than 65. It also pays for a $100,000 heart pump -- the ventricular heart assist device -- even though three of four recipients die within two years.
A feeding tube helped sustain Fran Cole's beloved mother when Parkinson's disease took away her ability to swallow. But as the disease progressed, and her mother became unresponsive, the tube's forced feeding became a curse.
Medicare should restrict payment for certain aggressive interventions in some dying patients, said Dr. Muriel Gillick, a geriatrician at Harvard Vanguard Medical Associates.
So, if the National Institutes of Health determines that comfort care is the best approach to advanced Alzheimer's disease, Medicare shouldn't pay for ICU, CPR, dialysis or other interventions, according to Gillick.
Doctors, too, should be better gatekeepers. Blind application of rapidly developing medical technologies "to any and every patient is not good practice of medicine," said Dr. Jeffrey Stoneberg of Alta Bates Summit Medical Center in Oakland.
They have a responsibility to use treatments on patients who will best benefit from them, he said, and to withhold therapies when the risks outweigh the benefits.
Hospitals need to exert their influence, not to create a financial barrier to survival, but to discourage extraordinary expenditures with little human payoff. Daly City's Seton Medical Center averts unnecessary or ineffective care through its "Medically Ineffective Care" policy. If a family insists on such care, the hospital can discharge the patient.
Cure 6: Offer better comfort care to patients in their final days
A lot of hospitals claim to have comfort, or palliative, care for dying patients. But there's no standard; at some places, such care may consist of a chaplain or part-time nurse who makes rounds to people in pain. Sometimes, patients and their families may not even know it exists.
This is a cure that hospitals can pioneer. Each facility needs a team of palliative care doctors and nurses to help us live every minute as richly as possible. The chronically ill need simple measures to control pain, ease anxiety and manage emphysema or heart failure. Give the team its own budget and make sure patients know it is available.
"If you do not know that there are other options to usual aggressive medical care, then you will never be able to choose them," Stoneberg said.
Some hospitals are even moving palliative care into the emergency room, to catch the very frail elderly before they are put on the "tube 'em and move 'em" conveyor belt to the ICU. New York's Montefiore Medical Center and Atlanta's Emory University are leading this effort, and their examples could be replicated nationwide.
Comfort care can even be moved into the community, keeping people like Marilyn Cronin, who at 58 suffers from lung disease and liver failure, in her Soquel home instead of the hospital. The Palo Alto Medical Foundation is successfully testing that approach, with old-fashioned house calls.
Cure 7: Pay families to help at home instead of using hospitals
Medicare will spend hundreds of thousands of dollars for us to stay in the hospital, but it's far less generous if we want to take care of our chronically ill loved ones at home. It does not pay for a live-in nurse, homemaker or home health aide. Your family or hired caregivers must provide months of bedside care. It pays for a nurse to visit only if you are receiving comfort care through hospice or have a "skilled nursing" need, such as changing bandages.
Federal policymakers need to expand home care benefits to ease the burden and expense on family caregivers and to support choices that are usually cheaper for taxpayers than hospital care. The National Alliance for Caregiving is appealing to Congress to boost funding for assistance, counseling, respite and other services for caregivers.
Dr. John Meyers, 84, spent his final months at home in San Mateo, only because of the careful financial planning and tireless efforts of his wife, Susan.
One of six Californians know her struggle, as they care for a sick or elderly family member.
"As a family, we had no idea how unprepared we were to go through the process," wrote reader Debbie Gary, who helped care for her mother at home.
Cure 8: Broaden use of comfort care through Medicare, insurance
Medicare's outdated policies limit our access to cost-effective and comforting end-of-life care like hospice -- and federal legislators must change that.
Hospice was still an experiment in the early 1980s, when the Reagan administration allowed it to be covered under Medicare. Now it has been proved to reduce both costs and suffering -- but the tough eligibility requirements haven't changed.
For instance, Medicare pays for the comfort care of hospice only if we quit seeking a cure. It's a diabolical either-or choice.
There's another problem: Medicare won't pay for hospice unless we are diagnosed to die within six months. That often denies it to dementia patients, who tend to live longer than cancer or heart disease patients.
An experiment by the Aetna insurance company shows a better way. Its "Compassionate Care Enhanced Hospice" let members enroll in hospice while continuing treatment. It also accepted members with life expectancies of 12 months. The results: a decrease in costly emergency room and intensive care. In 2010, Aetna added the feature to most of its medical plans.
The new health care reform legislation includes plans for enhanced hospice with Medicare patients, but the projects haven't been funded.
Ultimately, the cure is acknowledging that pointless suffering, not death, is the foe.
Our medical resources are squandered "when death is not seen as a natural part of life, but rather something that can be prevented or at least postponed as long as possible," said Stoneberg, the Alta Bates doctor.
After writing about my father's death, I've learned what I can't change: illness, aging and death. They are painfully and inevitably the human condition.
But our conversation has shown us how we can change: better informed decisions. Wiser use of technology. More judicious spending. Greater sensitivity. Less desperation.
These lessons could cure the conflict between "do everything" medicine and our desires for a peaceful passing, making it affordable enough, and humane enough, to ease the painfully high cost of dying.
Contact Lisa M. Krieger at 650-492-4098.
About the series
This story is part of a series examining end-of-life issues inspired by the emotional and financial costs of the final days of reporter Lisa M. Krieger's father.
Online extra
For information on how to manage your end-of life-care and to see other Cost of Dying stories, go to www.mercurynews.com/cost of dying.